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Session 105PD, Value Based Programs for the Medicare Population
Moderator/Presenter:
James P. Hazelrigs, ASA, MAAA
Presenters: Aaron P. Jurgaitis, ASA, MAAA Kelsey L. Stevens, FSA, MAAA
SOA Antitrust Disclaimer SOA Presentation Disclaimer
105PD: Value Based Programs for the Medicare Fee for Service PopulationAARON JURGAITIS, ASA, MAAA | WAKELY CONSULTING GROUPKELSEY STEVENS, FSA, MAAA | WAKELY CONSULTING GROUPJune 2018
• In an effort to reform how health care is delivered and paid for, value-based programs are intended to incentivize providers to focus on the quality of care, rather than the quantity of care, that they provide for their patients. CMS has been instrumental when it comes to tying payment to value on a large scale.
• This session will provide an overview of some of the payment and delivery system reforms that exist in Medicare Fee for Service today. It will evaluate early indicators of improvement in care outcomes and reduction in medical costs. Finally, it will explore the future direction of the major programs offered directly through CMS and through the Center for Medicare & Medicaid Innovation. This session is intended to meet the needs of actuaries who are focused on Value Based Design and/or Medicare.
Welcome
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Polling
• SOA Events app• More > Polls > Session 105• Results in real time….or are they?• Look engaged while playing Angry Birds
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Live Content SlideWhen playing as a slideshow, this slide will display live content
Poll: What is your current professional level of involvement with any of the CMS sponsored value based care programs?
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5%
27%
10%
43%
15%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
That's all I do! I work with them frequently, valuebased care is my main area of
practice.
I work with them frequently, butvalue based care is NOT my main
area of practice.
I encounter them occasionally, but Idon't work with them very much.
CMS. VBC. ACO. Enough with theacronyms. Isn't it happy hour anyway
What is your current professional level of involvement with any of the CMS sponsored value based care programs?
Why is this important to a payer actuary?
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Topics• Overview of payment and delivery system reforms• Early indicators of performance• Future direction
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Degree of Provider Integration & Accountability
Leve
l of P
rovi
der R
isk
Fee For Service
Quality Incentives
Performance Based Contracts
Bundle/Episode Payments
Shared Savings
Shared Risk
Global Payments
Capitation
• Value based program = care delivery reform + quality component + payment reform
• Value based care doesn’t describe a model, but a spectrum of models
Value Based Models
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Overview of ReformsPayment and Delivery Systems
• CMS• Medicare Shared Savings Program (Tracks 1, 2, 3)
• CMMI (Center for Medicare and Medicaid Innovation)• Next Generation ACO• Medicare Shared Savings Program Track 1+• Comprehensive Primary Care Plus (CPC+)• Bundled Payment for Care Improvement (current program and
upcoming Advanced)• Comprehensive Joint Replacement
• Advanced APMs under MACRA9
Risk adjusted care management fee paid quarterly to practices
Performance based incentive payment based on patient experience measures
Track 1: bill and receive payments as usual
Track 2: bill as usual, portion of payments held, quarterly
payouts for performance
Comprehensive Primary Care Plus (CPC+)• Regional multi-payer primary care medical home
model
• Program began 1/1/2017; next version of Comprehensive Primary Care that began in 2012
• 2,965 primary care practices participating in 18 regions, with 61 different payers
• Two tracks, with different requirements, upside and downside arrangements, and care management payments
• Quality component includes HEDIS utilization (IP/ED), patient experience surveys, and claims based measures
• Delivery system reform: increased focus on primary care
• Payment reform: pay for quality and quasi-capitation
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BPCI Track 2
• Acute and post-acute care
• Extends 30/60/90 days post-discharge
• Retrospective payment
• 48 inpatient episodes to select from
• 437 organizations/2,358 episodes
BPCI Track 3
• Post-acute only• Extends 30/60/90
days post-discharge• Retrospective
payment• 48 inpatient
episodes to select from
• 599 organizations/7,012 episodes
BCPI Track 4
• Acute and post-acutecare
• Extends 30/60/90 days post-discharge
• Prospective payment• 2 organizations/13
episodes
BPCI Advanced
• Acute and post-acutecare
• Extends 90 days post-discharge
• Retrospective payment
• 29 inpatient/3 outpatient episodes
• TBD
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Benchmarks set based on three years of provider specific experience, with a discount applied. Stop loss percentiles are selectable.
Bundled Payments for Care Improvement (BPCI)• The bundled payment program enables providers to engage in a value-based
arrangement for selected episodes of care• Program originally started in 2013, being replaced with BPCI-Advanced 10/2018• Quality metrics contain both episode specific and general components
• Delivery system reform: provide more efficient care during and after an acute care stay
• Payment system reform: episodic capitation
Comprehensive Joint Replacement (CJR)• Subset of the BPCI program, focused solely on lower
joint replacement (DRG 469 and 470)
• Originally mandatory for providers in 67 MSAs• In August 2017 mandatory MSAs reduced to 34,
with remaining 33 moved to a voluntary participation basis
• Benchmarks set based on a blend of provider specific and regional rates in years 1-3, moving towards full regional rate pricing in years 4-5
• Program runs from 4/2016 through 12/2020
• Quality metrics measure complication rates and patient satisfaction
• Delivery system reform: provide more efficient care during and after an acute care stay
• Payment system reform: episodic capitation
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Live Content SlideWhen playing as a slideshow, this slide will display live content
Poll: Do you believe that the CMS value based programs have the ability to reduce costs, improve the patient experience, and improve the quality of
care?
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8%
75%
8%10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
It's happening already. I've seen it. Yes, but it will take some time. No, we need more marketplace momentumfrom providers.
I'm skeptical, did we already try this andabandon it
Do you believe that the CMS value based programs have the ability to reduce costs, improve the patient experience, and improve the quality of care?
Next Generation ACO• ACO program with mandatory downside risk
• Program runs 2016 – 2020
• Prospective assignment
• One year baseline period has trend, risk adjustment, and discount applied to calculate benchmark
• Available benefit enhancements:• Telehealth expansion• Post-discharge home visit waiver• 3-Day SNF waiver
• No minimum savings/loss rate; first dollar savings/losses
• Growth from 18 participants in 2016 to 51 in 2018
• 10,000+ required beneficiaries to participate (7,500 for rural ACOs)
• 31 quality measures
• Excludes Part D expenditures
• Payment mechanisms available to ACOs:• Regular FFS• Discounted FFS with discount amount paid to ACO• Capitation (All-Inclusive Population Based Payment)• + Population based payment (<=$6 PBPM)
• Delivery system reform: increased integration of care, right care at the right place at the right time
• Payment system reform: putting providers at risk for value and volume
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• Delivery system reform: increased integration of care, right care at the right place at the right time
• Payment system reform: putting providers at risk for value and volume
Medicare Shared Savings Program ACO• ACO program with varying levels of upside and downside
potential
• Program began 4/2012, and has gone through some notable changes over time
• Renewal benchmarking, E&M codes for assignment, total vs. assignable population
• Retrospective or prospective assignment, depending on the track
• Three year baseline period has trend, risk adjustment, and adjustments upon renewal applied to calculate benchmark
• Emphasis in shifting ACOs towards downside risk as they continue in the program
• 3-Day SNF waiver for some tracks (1+, 3)
• Minimum savings/loss rates based on population or selected by ACO; savings/losses go back to first dollar
• 31 quality measures
• Excludes Part D expenditures
• Program has grown from 220 ACOs in 2012 to 561 ACOs in 2018
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Topics• Overview of payment and delivery system reforms• Early indicators of performance
• All information on the following slides is from publiclyavailable data sources. Not every program has the sameavailability, detail, or history of results.
• Future direction
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Live Content SlideWhen playing as a slideshow, this slide will display live content
Poll: Were you aware of the scope of results published by CMS related to these programs?
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14%
37% 37%
12%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Yes, data.cms.gov is my homepage. I knew it existed, but I haven't really exploredit.
No. Just no. Are we closer to happy hour now
Were you aware of the scope of results published by CMS related to these programs?
CPC+• Calendar Year 2017 recap
• 1,365 Track 1 practices• 1,511 Track 2 practices• 96% persistency from prior CPC program• 46% of practices participate in MSSP
• Outcomes• Improved risk stratification of the population• Collaborative care agreements with specialists• Increased speed of information sharing surrounding IP events• 96% of practices with 24/7 coverage by a clinician
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BPCI• Yearly recap of results performed by the Lewin Group; no data published beyond Lewin’s report• Major themes:
• Episode Initiators (acute care facilities) tended to be in larger urban settings, with strong presence of academic medical centers
• Episode Initiators started off with higher costs relative to non-participating providers• Selected bundles varied by model, with major joint replacement of lower extremity (MJRLE)
popular with model 2, and CHF, COPD, and pneumonia/respiratory infections popular among model 3; very few model 4 participants
• When segmenting by model, type of care (anchor vs. post-acute care), and episode, there was little statistical significance in aggregate cost reductions or change in quality
• Instances of significance were very focused: cost reductions in MJRLE due to PAC utilization in model 2, MJRLE SNF cost reduction in model 3, and a substitution of home health for institutional PAC
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Quality Category Episodes
Average Reconciliation
Per EpisodeAcceptable 1,629 $1,093 Good 13,058 $1,157 Excellent 18,465 $1,121 Total 33,152 $1,134
CJR• Results for 4/2016 – 12/2016• Publicly available results only include those providers that earned reconciliation payments• Highest volume MSAs (38% of episodes): New York, Los Angeles, Indianapolis, Pittsburgh, San Francisco• Average reconciliation per episode was consistent across quality categories ($1,093 - $1,157), with the majority of episodes rated as good
or excellent
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Next Generation ACO• Results for CY2016• Publicly available results for 18 original
participants
• 7 of 18 had losses, owing CMS $20.3m• 11 of 18 had gains, earning $58.3m
• Overall savings to ACOs of $38m• Program produced overall savings to
CMS of $10.3m• Gross savings/losses – net
savings/losses• All ACOs received 100% credit for
quality, actual quality scores were reported
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• CAHPS patient satisfaction surveys came back mostly positive
• Improvement opportunities on health education and stewardship of patient resources
Next Generation ACO
Next Generation ACO
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• Favorable performance on most preventive health measures
• Good prevalence of various screenings and vaccines
• Opportunity for improvement on depression screening
Live Content SlideWhen playing as a slideshow, this slide will display live content
Poll: How important is the detailed claims data that CMS gives to providers to the success of these programs?
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29%
66%
3%2%
0%
10%
20%
30%
40%
50%
60%
70%
Utmost importance. These programs wouldn'tfunction if providers didn't have that data.
It's great information, but not enoughproviders are leveraging the data.
It's not important at all. Providers don't knowhow to use the data they receive.
Ummm, providers are getting data from CMS
How important is the detailed claims data that CMS gives to providers to the success of these programs?
MSSP ACO • The Medicare Shared Savings Program has shown growth in participating organizations year over year, reaching a high of 561 ACOs in 2018
• ACOs within their first 3 year agreement period have high year over year persistency at 93%
• ACOs in their second 3 year agreement period have lower persistency at 89%
• Renewal year persistency decreases to 79%, with the notable low points occurring in the first renewal year, 2016
• The number of covered beneficiaries has increased from 3.2m in 2013 to 10.5 in 2018
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• As an ACO's tenure in the program increases, they are more likely to achieve shared savings. Development and implementation of intervention programs takes time, and realizing gains from those can take additional time.
• Some of the 2012/2013 starters that had savings in earlier years didn’t achieve savings in 2016, the year that historic benchmarks were reset.
MSSP ACO
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• The number of ACOs achieving net shared savings has continued to grow each year, with the amount of the savings to each ACO growing as well
• Average net shared savings per ACO contracted from 2013 to 2014, after which point it expanded again and has remained relatively stable in 2015 and 2016
• CMS is in an opposite position, with the program exceeding cost projections each year
• Like many aspects of this program, this seems to be impacted by longevity of the participating organizations
• Downside ACOs produced a gain for CMS each year ($8m, $10m, $10m, $33m)
MSSP ACO
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• One of the goals of this program is to increase coordinated care, with PCPs at the nexus of that coordination
• Many ACOs will couple this with reducing unnecessary or avoidable facility utilization
• Results thus far show promising trends in:• Bacterial pneumonia and CHF
discharge rates• Short-term hospital stay discharge
rates• ED visits that lead to hospitalization
rates• Rates of primary care services with
NP/PA/CNSs
2013 2014 2015 201612 month results 12 month results 12 month results
Person-Years per Assigned Beneficiary Medicare Enrollment TypeTotal 3,288,745 5,169,694 7,057,142 7,669,535
End Stage Renal Disease 31,755 51,383 63,221 67,412Disabled 470,969 729,669 969,333 988,112Aged/Dual 228,493 334,601 404,529 566,165Aged/Non-Dual 2,557,529 4,054,040 5,620,059 6,047,846
Transition of Care/Care Coordination Utilization30-Day All-Cause Readmissions Per 1,000 Discharges 150 171 168 16630-Day Post-Discharge Provider Visits Per 1,000 Discharges 769 781 782 791
Ambulatory Care Sensitive Conditions Discharge Rates Per 1,000 BeneficiariesChronic Obstructive Pulmonary Disease or Asthma 9.94 8.97 10.34 9.99Congestive Heart Failure 13.25 13.49 13.27 11.72Bacterial Pneumonia 10.15 9.00 8.50 7.67
Additional Utilization Rates (Per 1,000 Person-Years)Hospital Discharges, Total 326 328 321 319
Short-Term Stay Hospital 300 302 295 293Long-Term Stay Hospital 4 3 3 3Rehabilitation Hospital or Unit 12 12 13 13Psychiatric Hospital or Unit 11 10 10 9
Skilled Nursing Facility or Unit Discharges 84 76 73 71Emergency Department Visits 697 702 711 719
Emergency Department Visits that Lead to Hospitalizations 230 224 219 214Computed Tomography (CT) Events 680 705 735 779Magnetic Resonance Imaging (MRI) Events 273 279 286 298Primary Care Services 9,968 9,867 9,822 10,127With a Primary Care Physician 4,157 4,029 3,877 4,033With a Specialist Physician 4,707 4,663 4,619 4,691With a Nurse Practitioner/Physician Assistant/Clinical Nurse Specialist 894 958 1,083 1,122With a FQHC/RHC 210 217 244 281
MSSP ACO
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• Generally consistent quality metrics in patient/caregiver experience category year over year• Similar to Next Generation ACO, opportunity for improvement in stewardship of patient
resources
MSSP ACO
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• Preventive health quality domain has shown strong improvement in almost every metric year over year
MSSP ACO
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Early Indicators of Performance• So what does it all mean?• Aggregate financial results are varied from a provider perspective• Aggregate financial results are leaning towards unfavorable from a CMS
perspective• Lack of downside• Conclusion based on a few programs, lack of information to prove this
• Quality results are generally favorable, and in cases where we can see, improving• In the MSSP program, some key utilization metrics show favorable results,
pointing towards shifts in how care is delivered, while keeping quality high
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Early Indicators of Performance• How do you define success?• All agree on the Triple Aim, but CMS and
providers might have different definitions beyond that
• Provider revenues• Bent cost curves• In-network care• Appropriate care at the right time in the right setting• Access to data
35
Topics• Overview of payment and delivery system reforms• Early indicators of performance• Future direction
36
Live Content SlideWhen playing as a slideshow, this slide will display live content
Poll: Are payers and providers doing enough with Value Based Care programs to positively impact the health system?
38
2%
48%
37%
13%
0%
10%
20%
30%
40%
50%
60%
Yes. CMS is the country's largest payer and ifthey continue doing this we'll see impacts.
Maybe, but we need more collaborative multi-payer programs available.
No. We need more payers and providers toparticipate.
How many more slides do we have
Are payers and providers doing enough with Value Based Care programs to positively impact the health system?
Future Direction
• Data• Increasing variety of programs being offered• Increasing opportunities for multi-payer partnerships• Targeting of wider variety of providers for participation• Responsiveness to industry feedback and appetite for
revisions• Implementation of MACRA (Medicare Access and CHIP
Reauthorization Act)
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MACRA, signed into law in 2015, created the Quality Payment Program. Most providers who accept Medicare payments have toparticipate in one of two tracks under the QPP: MIPS or an Advanced Alternative Payment Model (APM).• MIPS requires reporting by providers and grades them against other participants to modify FFS reimbursement• Advanced APMs require a provider to take on more than nominal downside risk in delivery of high quality care
MACRA/Quality Payment ProgramDriving participation in value based models
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Future Direction
Leve
l of P
rovi
der R
isk
Degree of Provider Integration & Accountability
Fee For Service
Quality Incentives
Performance Based Contracts
Bundle/Episode Payments
Shared Savings
Shared RiskGlobal Payments
Capitation
MIPS
APMs
Advanced APMs
Spectrum of Value Based Models
41
Questions?
