ACOs, QPP, and VBP: Oh MI!

Flex Reverse Site VisitJuly 17, 2018

Rural Health Value

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Vision: To build a knowledge base through research, practice, and collaboration that helps create high performance rural health systems

• HRSA FORHP Cooperative agreement

• Partners: RUPRI Center for Rural Health Policy Analysis and Stratis Health

• Activities: Resource development and compilation, technical assistance, research

• www.ruralhealthvalue.org

Michigan Center for Rural Health (MCRH)

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Our vision: “the Michigan Center for Rural Health will be universally recognized as the center for expertise for rural health in Michigan through creative and visionary education, service, and research.”

Our mission: “to coordinate, plan, and advocate for improved health for Michigan's rural residents and communities.”

Board of Directors: • Michigan State Senate• Michigan Osteopathic Association• MDHHS - Bureau of EMS Trauma and Preparedness• Michigan State Medical Society• Michigan Department of Health and Human Services – Policy, Planning and Legislative Services• Michigan Health & Hospital Association• Michigan Nurses Association• Michigan Association for Local Public Health• Michigan House of Representatives• Michigan Primary Care Association• MSU College of Osteopathic Medicine• Office of the Governor

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MCRH Programs

Standard Federal Office of Rural Health Programs (FORHP) Programs (our foundation)• State Office of Rural Health (SORH)

– Assist states in strengthening rural health care delivery systems by maintaining a focal point for rural health within each state

– Continuing Education– Recruitment/Retention

• Medicare Rural Hospital Flexibility (Flex) Grant Program

• Small Hospital Improvement Program (SHIP)

Supplemental Programs • Hospital Improvement Innovation

Network (GLPP HIIN)• Great Lakes Practice Transformation

Network (GLPTN)• Quality Payment Program (QPP)• Manage 2 Accountable Care

Organizations (ACOs)• Manage a Clinically Integrated

Network (CIN)• Opioid Focused Sub-Contract

– MDHHS – Prescription Drug Overdose Prevention Initiative

– Rural Access to Treatment Grant Program

Objectives

• Identify key aspects of three value-based payment programs and their relevance for rural providers and critical access hospitals (CAHs).

• Understand how these value-based programs are being implemented and supported in rural Michigan.

Focus on value is not diminishing…

Source: https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-value-based-transformation-to-the-federation-of-american-hospitals.html

“There is no turning back to an unsustainable system that pays for procedures rather than value. In fact, the only option is to charge forward — for HHS to take bolder action, and for providers and payers to join with us.”

Alex M. Azar II, Secretary of HHS, March 5, 2018

(Remarks to the Federation of American Hospitals)

Form Follows Finance

• How we deliver care depends on how we are paid for care.

• Health care reform is changing both payment and delivery.

• Fundamentally, reform involves transfer of financial risk from payers to providers.

Value-based Payment Taxonomy

https://hcp-lan.org/groups/apm-framework-refresh-white-paper/

Payment Risk Continuum

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CMS Drive to Value-based Payment

• Hospital Value-Based Payment Program

• Quality Payment Program (as a result of MACRA, the Medicare Access and CHIP Reauthorization Act)

– MIPS (Merit-based Incentive Payment System)

– Advanced Alternative Payment Models

• Medicare Shared Savings Program (Accountable Care Organizations)

CMS Hospital Value-Based Purchasing (VBP) Program

• 2% withhold, which can be “clawed back” based on performance scores (high performance or improvement)

• 2018 performance domains

– Experience of Care/Care Coordination (25%)

– Safety (25%)

– Clinical Care - Outcomes (25%)

– Efficiency/Cost Reduction (25%)

• VBP is for PPS hospitals only

BCBS of MI: Rural Hospital Pay for Performance (P4P)• 2018-2019 Program:

– Hospital‐wide patient safety assessment survey at least once every two years

– Determines up to 6 percent of a rural hospital’s payment rate for the following year. Participation is mandatory.

– Four program areas:• HCAHPS

• Clinical Quality Indicators

• Population Health Management

• Quality Initiatives

• Most CAHs have received the full incentive payment since the program launched

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Scoring:• Performance against

benchmark• Attestation of activities• Participation in QI

initiatives with MICAH and HIIN

Source: https://www.bcbsm.com/providers/value-partnerships/hospital-pay-for-performance.html

Quality Payment Program (QPP)• Medicare’s new approach to paying physicians and other

clinicians as a result of MACRA (Medicare Access and CHIPReauthorization Act)

Two tracks:– Merit-based Incentive Payment System (MIPS)

• Eventually -9% to +27% adjustment in pay

• Consolidates three existing programs (PQRS, VBM, MU) and adds a new category (improvement activities)

– Advanced Alternative Payment Models (APMs)• 5% APM bonus• Excluded from MIPS performance reporting requirements

Most physicians/clinicians will initially be paid under the MIPS track

• Baseline data 2017 = First bonus/penalty 2019• 94% of MIPS eligible clinicians in rural practices

participated in 2017.

www.qpp.cms.org

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Quality Payment Program cont.

• MIPs categories:

• Complex program with numerous variables

• Technical Assistance:

– QIN-QIOs (15 or more clinicians)

– SURS (Small, underserved, rural – less than 15)

– PTNs (Practice Transformation Networks)

For more information: www.qpp.cms.org

Great Lakes Practice Transformation Network (MI, KY, IN, IL)

• Transforming Clinical Practice Initiative (TCPI)

• Quality Improvement Advisor focusing on small and independent practices.

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One MI CAH Story

• The hospital had decided to report via claims. However, the claims score was very low, the claims data appeared to be incorrect.

• Started working with hospital information technology department and Evident (EHR) vendor. After a couple of months the hospitals EHR was finally able to produce a QRDA III file which we test in MIPScast along with using the meaningful use report for each provider we calculated the MIPs score.

• Assisted hospital in selecting Quality measures• Developed work plan to move the hospital along in the phases of transformation

for the TCPI program• 2016 measures were reported through registry to avoid 2018 reduction in

Medicare payments• Worked with hospital and EHR vendor to produce a QRDA III file• Assisted hospital with Meaningful use report, strategies and requirements • Hope to use MIPs report to further review measures for the future and use the

QRUR report to look further into costs

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Accountable Care OrganizationsGroups of providers (generally physicians and/or hospitals) that receive financial rewards to maintain or improve care quality for a group of patients while reducing the cost of care for those patients.*

How Medicare ACOs (called Medicare Shared Savings Programs) work:

*Source: David I. Auerbach, et al, Accountable Care Organization Formation Is Associated With Integrated Systems But Not High

Medical Spending, Health Affairs, 32, no. 10 (2013):1781-1788.

▪ Beneficiaries attributed to ACO based on where they receive primary care

▪ Medicare pays fee-for-service (not capitation)

▪ CMS shares 50% of difference between estimated and actual cost

▪ But shared savings percent will be reduced if suboptimal quality

ACO Financing

All existing reimbursement stays the same.

ACO’s Year 1

Spending

per Patient

Shared

Savings

(50%)

Quality Score

Adjusted Shared

Savings

ACO’s Baseline

Spending per Patient

Presence of ACOs

• Rapid growth of Medicare ACO/Shared Savings– August 2012: 220– January 2015: 393– January 2016: 433 – January 2018: 561

• Both hospital and physician led• CAHs: 421 participating nationally• Only 13% of non-metro counties have NO Medicare FFS

beneficiaries in an ACO• 22% of non-metro counties have more than 30% of

Medicare FFS attributed to and ACO

Sources: CMS - Medicare Shared Savings Program Fast Facts , RUPRI Center for Health Policy:Medicare Accountable Care Organization Growth in Rural America, 2014–2016

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2015 Medicare Shared Savings Program (MSSP) Results

• 400 ACOs = $466 million savings

• ACOs improved on 84% of Quality Improvement measures from Year 1 to Year 2

• 125 ACOs qualified for shared savings

• Rural ACOs outperformed urban ACOs on several financial and quality metrics

Source: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-25.html 22

Michigan’s Rural ACO Journey

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ACO Investment Model (AIM)

• The AIM funded Medicare Shared Savings Program (MSSP) is a Medicare/CMS program that allows providers to continue to be paid fee-for-service and/or cost-based reimbursement, while gaining the infrastructure, tools, and knowledge to manage population health.

• If a group of providers are successful in reducing costs, while meeting patient satisfaction and quality thresholds, they can share in up to 50% of the savings. If costs go up, there is no penalty or payment due from the providers.

• Three year program January 1, 2016 – December 31, 2018

ACO Investment Model Payment

ACOs participating in the AIM funded MSSP received these payments on January 1, 2016:

• an upfront fixed payment of $250,000

• an upfront variable payment of $36 per assigned Medicare beneficiary (based on preliminary prospectively-assigned beneficiaries); and

• a monthly payment of $8 per Medicare beneficiary permonth (based on preliminary prospectively-assigned beneficiaries).

ACO Investment Model

Core Components of the Program

– Care Coordination

• Care Coordination Management and Transitional Care Management Billing

– Annual Wellness Visits

– Claims Data Analysis (core to reducing costs and improving population health)

• Referral Patterns

• Patient usage/spend

• Chronic Conditions

Mic

hig

an’s

Ru

ral A

CO

s• Sheridan Community Hospital (CAH)

• Scheurer Hospital (CAH)

• Hills & Dales General Hospital (CAH)

• Marlette Regional Health System (CAH)

• McKenzie Health System (CAH)

• Helen Newberry Joy Hospital (CAH)

• Schoolcraft Memorial Hospital (CAH)

• Alcona Health Center (FQHC)

• Hayes Green Beach Memorial Hospital (CAH)

• Sturgis Hospital (PPS)

• Three Rivers Health (PPS)

• Hillsdale Hospital (PPS)

• Community Health Center of Branch County (PPS)

• Allegan General Hospital (PPS)

• Memorial Medical Center (CAH)

• Deckerville Community Hospital (CAH)

Gre

ater

MI R

ura

l AC

OSo

uth

ern

MI R

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Map of ACO Communities

Claims Data Analysis: Merging Claims Data with EHR

Risk Analysis of McKenzie Health System’s Attributed Medicare Beneficiaries

Using Claims Data to Leverage Partnerships

First Year Results

• Greater Michigan Rural ACO Medicare hit all 34 quality measures and Medicare spending is flat.

• Southern Michigan Rural ACO hit all 34 quality measures and reduced Medicare spending 1.5%.

• The Caravan Health ACO Model works.

• The ACO members view it as a “Scholarship” to learn and implement a Value-Based Program.

• MCRH is getting a Value-Based Program education.

CMS Models Are Only Part of the Story• Growth in Medicare Advantage

– Non-metro enrollment in 2017: about 2.4 million nationally (23%)

• State Medicaid Program Redesign– Managed Care– ACO-type payment structures

• Commercial/Private Insurance– Increasing costs/patient risk-sharing– Narrow networks

Value-based payment is here to stay!(but acronyms and programs likely to change)

Medicare Advantage Data: https://www.public-health.uiowa.edu/rupri/maupdates/nstablesmaps.html

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Resources• Rural Health Value:

Catalog of Value-Based Initiatives for Rural Providershttps://cph.uiowa.edu/ruralhealthvalue/InD/Briefs/

• Kaiser Family Foundation: Payment and Delivery System Reform in Medicare: A Primer on Medical Homes, Accountable Care Organizations, and Bundled Paymenthttp://kff.org/report-section/payment-and-delivery-system-reform-in-medicare-a-primer-executive-summary/

• Brookings Institute: The Beginners Guide to New Health Care Payment Models https://www.brookings.edu/blog/health360/2014/07/23/the-beginners-guide-to-new-health-care-payment-models/

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www.ruralhealthvalue.org

Michigan Program Resources

• Blue Cross Blue Shield Peer Group 5 Pay for Performance

• Quality Payment Program Resource Center

• Transforming Clinical Practice Initiative

– Great Lakes Practice Transformation

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Questions?

• Karla Weng, MPH, CPHQkweng@stratishealth.orgwww.ruralhealthvalue.org

• John Barnas

John.barnas@hc.msu.edu

• Crystal Barter

crystal.barter@hc.msu.edu

This presentation was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement 1 UB7 RH25011‐01]. The information, conclusions and opinions expressed in those of the authors and no endorsement by FORHP, HRSA, HHS should be inferred.