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9/13/2017
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Alternative Payment Models: Payment Model Innovations in Long-Term
and Post-Acute Care
September 26, 2017
“An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.”
Alternative Payment Model
Source: CMS Quality Payment Program
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Learning Objectives Develop an understanding of new payment models such as
Medicare ACOs and post-acute bundled payment programs Identify the key reasons to consider participation in APMs Understand the primary opportunities for long-term and post-
acute organizations Evaluate your organization’s readiness to participate
Overview Why are (APMs) Important?
APMs that are active today
What to expect if you wish to participate in APMs
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Understanding the Current State: Overall Health Care Industry Quality and Value Based Purchasing
o DHHS proposed 50% Medicare fees tied to quality or Value Based Purchasing by 2018
MedPac o Better quality care while incentivizing
providers to constrain cost and control spending
o Reduce rates
CMMI – Center for Medicare & Medicaid Innovation (the Innovation Center)
Growth outside of government payors o Medicare Advantage plans are implementing
or establishing goals for value-based payments
CMS is working with plans on multi-payor initiatives to align FFS and managed care value-based payment goals
Where Innovation Models Are Being Run or Tested Nationally
Source: https://innovation.cms.gov/initiatives/map/index
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Where Innovation Models Are Being Run or Tested in Pennsylvania
Source: https://innovation.cms.gov/initiatives/map/index
Medicare Money Linked to APMs
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Current State: Home Health and Skilled Nursing Industries Continued changes and price pressure from traditional payment sources
o Rebasing o Pre-claim review o Increased Medicare Advantage enrollment o Home Health Value Based Purchasing; SNF Value Based Purchasing (2019) o New Medicare home health payment model on horizon o Emphasis on outcomes
Shift From Fee For Service to Value Payments
Lower Risk --------------------------------------------------- Higher Risk
FFS Episodic Performance
Based Bundled
Shared Savings/ Shared
Risk
Capitation
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Why Engage with APMs?
Home Health and SNF Partnership Opportunity o Alternative sources of revenue share
in risk/reward o Show value o Increase market share
Speed at which APMs are made available has been increasing
Strategic partners are requesting it Future benefits that may be outside
of the APM (data)
Accountable Care Organizations (ACOs) Introduced in 2011 as part of the ACA Composed of service providers and suppliers
that are assigned a population of Medicare beneficiaries with the goal of improving quality and experience of care while reducing the rate of growth in health care spending o Beneficiaries continue to have the right to choose
providers
ACOs are assessed for quality and financial performance
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ACO Details
•Providers continue to receive FFS reimbursement
•Financial benchmarks are assigned based on historical expenditures for assigned beneficiaries
•Quality performance standards must be met to receive shared savings payments
Payments
•Pioneer ACO
•Medicare Shared Savings Program
•Next Generation ACO
Types of ACOs
Shared Savings Program -2016 Figures
433 ACOs Cover 7.7 Million
Beneficiaries
Program Savings $429 million
84% overall improvement in
quality measures from
2014 to 2015
119 ACO earned shared savings and met quality
standards
2012 – 42% Savings
2013 – 37% Savings
2014 – 22% Savings
2015 – 21% Savings
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Pioneer ACO
Medicare Pioneer ACO 32 health organizations
in 2012 8 in 2016 Initial incentive for
data submission Following years shared
savings and loss model
2016 results
o 12 Pioneer ACO total model savings $37 million
o 4 Pioneer ACO generated losses
Next Generation ACO Model Began January 2016 45 participating ACOs Higher levels of financial risk and
reward Testing Population Health models
driven by capitated payment Waivers for:
o Expanded use of telehealth o Skilled nursing home 3 day rule o Post-Discharge Home Visits
Encouraging cross continuum care
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Home Health and SNF ACO Opportunity Preferred Provider Agreements with
ACOs with a focus on: o Care Coordination/Transitions o Increased Efficiency for Seeing Patients
Timely o Improving Quality of Care o Sharing Data
CMS Approval Process o Review of Quality Scores
Emphasis on Home Health and SNF Partnerships
Bundled Payment Care Initiative (BPCI) Models BPCI vs ACO
o BPCI only apply to model descriptions vs ACO applies to group of beneficiaries
Model 1 – Retrospective Acute Care Inpatient Stay Model 2 – Retrospective against Target Price
o Inpatient stay initiates Episode o Episode runs 30, 60 or 90 days
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Bundled Payment Care Initiative (BPCI) Models Cont’d Model 3 – Retrospective with actual expenditures
against target price o Episode triggered with hospital stay o Episode STARTS with post acute services within 30 days of
discharge acute care o Ends 30, 60 or 90 days
Model 4 – Bundled payment covering hospital, physicians, practitioners o Episode begins with hospital stay o No claims submitted to MC o Related 30 day readmissions part of bundle
Comprehensive Care for Joint Replacement (CJR) Model Initiated 2016 for select 67 geographic areas Hip and knee replacement surgeries MS DRG 469 and 470 Episode of care starts at admission and ends 90 days post
discharge Providers and suppliers paid per usual FFS End of year expenditures compared to Medicare target
episode pricing Post acute collaborators encouraged to collaborate with care
redesign Post acute collaborators can include risk sharing and rewards 2017 new DRG for hip and femur fractures added to CJR
model
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Cardiac Care Bundled Payment
Recently delayed and now effective on October 1, 2017 Episode starts with admission to hospital with MI or
CABG surgery Inpatient stay and 90 days post discharge FFS payment continues End of year spending compared to Medicare quality
adjusted target episode pricing Post acute providers encouraged to collaborate Post acute providers can participate in risk or shared
savings Downside risk does not start until performance year 3
Medicare Access and CHIP Reauthorization Act (MACRA)
Replaced the Physician’s Sustainable Growth Rate Formula
Physician payments now connected to quality and cost of care provided
Physician can choose two programs: o Merit-Based Incentive Payment System (MIPS) o Advanced Alternative Payment Model (Advanced
APM)
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MACRA Cont’d Payment Adjustments MIPS
o Payment adjustments are weighted for score quality, resource use, meaningful use and practice improvement 2019 +/- 4%, 2020 5% , 2021 7%, 2022 9% 2019 to 2024 Exceptional performers may have additional
adjustments 2026- 0.25% annual baseline payment update
Advanced APM o 2019 – 2024 includes a 5% annual lump sum bonus o Transition into payment with more risk o 2026 and beyond 0.75% annual baseline payment
update
MACRA Cont’d Physicians must report data through PQRS or 2%
reduction o HH Agencies and SNFs can help with PQRS
reporting by providing data from OASIS and SOC and MDS and admission data Flu Vaccination Pneumococcal Vaccination Weight Assessments and counseling Tobacco use and cessation Fall Risk Assessment Fall Plan of Care
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Medicare Care Choice Model 141 participants in the model Model is designed to:
o Increase access to supportive care services provided by hospice
o Improve quality of life and patient/family satisfaction
o Improve new prospective payment systems for the Medicare and Medicaid programs
Been difficult for hospices to identify eligible patients with most participating hospices having less than 15 participants
Reimbursement is $200 to $400 per patient per month
Value Based Purchasing- Home Health CMS mandated in 9 states Episode begins with admission to Home Health and ends
with episode Based on OASIS Outcomes, HHCAHPS, claims data, and
other measures Compete against other providers in your state Benchmark, Achievement Threshold, and Improvement
scoring on each outcome Starting in 2018, episodic reimbursement will be based
on TPS score with +/- 3% and increasing to +/- 8% in 2022
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Value Based Purchasing- What to Expect with SNF Program to start in fiscal year 2019 Payment will be based on quality of care, not just quantity of
services Based on established measures
o Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) Estimates the risk of unexpected readmissions for FFS Medicare
patients at PPS, Critical Access or Psychiatric Hospitals or any cause or condition
o Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) Estimates the risk of preventable readmissions for FFS Medicare
patients at PPS, Critical Access or Psychiatric Hospitals or any cause or condition
APM Expectations in the Home Health
and SNF Setting
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Get paid less to do more Expect to see higher acuity patients Easy CJR, AMI, and CABG patients
may skip right over home care to the outpatient setting
Increase in LUPA claims and short SNF LOS and low therapy utlization
Agencies need to improve service delivery time o Be cognizant of impact to quality of
care o Discharge planning
Need for true partnerships across a variety of provider types to impact/change culture o Ex - CJR patient education on post
acute care prior to surgery
What to Expect
Don’t assume that health system APM participants are utilizing their own providers
Be patient and persistent! o Typically takes 12-18 months to go
through this process
Develop programs that health systems view as valuable o Preventing ER visits o Discharging patients to home from
ER o SNF bypassing and/or earlier SNF
discharge
Health system hiring of care coordinators/navigators vs. home health
Does the APM incentives align with the HHA or SNF?
Strategic Partnerships
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Share Your Organization’s Story!!! Ability to Manage Readmissions Patient Outcomes Relative to
Peers Episodic Management
Capabilities Knowledge of Care Planning Focus on Patient Centered Care Scope of Service Lines and
Outcomes Data Sharing with Partners
Create your own playbook with the goal of how to eliminate the need for hospitalization
Value Proposition
Market Analysis o Review CMS map to determine what
APMs are happening in your market o Are you getting referrals from these
APM participants? o What does your data show for these
referrals sources?
Organizational Analysis o Review CMS map to determine what
APMs are happening in your market o Are you getting referrals from these
APM participants? o What does your data show for these
referrals sources?
Outcomes Analysis o Do your outcomes show value to
your potential partner?
What to do next?
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QUESTIONS?
Contact Information: www.BlackTreeHealthcareConsulting.com
Diane Link RN, MHA
o Director, Clinical Services
Vicki Freedman, MBA
o Associate
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Thank you!
