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4/12/2017
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UNBUNDLING THE CARDIAC BUNDLE
Success with Episode Payment Models
X. Lucy Zhang, RNSenior [email protected]
Eric RogersSenior Managing Consultant
April 13, 2017
David W. Stein, MD, FACS, ENTPhysician and President of
Strategic Medical Consultants
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• Participate in entire webinar
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Complete group attendance form with
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Answer polls when they are provided
• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar
TO RECEIVE CPE CREDIT
UNBUNDLING THE CARDIAC BUNDLE
Success with Episode Payment Models
X. Lucy Zhang, RNSenior [email protected]
Eric RogersSenior Managing Consultant
April 13, 2017
David W. Stein, MD, FACS, ENTPhysician and President of
Strategic Medical Consultants
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• Ruling Overview & Implications
• Key Elements
• Implications & Next Steps
• Q&A
AGENDA
EPISODE PAYMENT MODELS OVERVIEW
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• Latest updates Implementation date delayed from
July 1 to October 1
CMS is taking comments regarding further delaying until January 1, 2018
THE FUTURE IS UNCERTAIN
“We insist CMMI stop experimenting with Americans’ health & cease all current & future planned mandatory initiatives within the CMMI”
– Letter from Tom Price to
CMMI in September 2016
Best Time to Act is NowRegardless of political climate, quality‐based reimbursement is here to stay. Providers who prepare early are better poised to succeed
EPISODE PAYMENT MODELS (EPMS) CREATED FOUR MODELS
Acute Myocardial Infarction (AMI)
Model
Three AMI MS‐DRGs
•280
•281
•282
Six PCI MS‐DRGs (with AMI diagnosis in principle or secondary positions on IPPS claim)
•246
•247
•248
•249
•250
•251
Coronary Artery Bypass Graft (CABG)
Model
Six MS‐DRGs
• 231
• 232
• 233
• 234
• 235
• 236
Cardiac Rehabilitation (CR) Incentive Payment Model
Four HCPCS
• 93797
• 93798
• G0422
• G0423
Surgical Hip & Femur Fracture Treatment (SHFFT) Model
Three MS‐DRGs
• 480
• 481
• 482
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• Five‐year model from October 1, 2017 to December 31, 2021
• Episode starts on admission & ends 90 days after day of discharge
• Hospitalization must be at a participant hospital & patient must be eligible Medicare beneficiary discharged under MS‐DRGs within EPM scope
EPM DEFINITION & TIMELINE
Downside risk begins
Voluntary downside risk begins
Included Excluded• IP hospitalization (including related readmissions)
• IRF
• SNF
• IP psych facility
• Home health agency
• Outpatient services
• Independent OP therapy
• Clinical lab services
• DME
• Physician services
• Part B drugs
• Hospice
• Hospital readmission DRGs related to
Oncology
Trauma medical
Surgery for chronic & acute conditions not likely related to care provided during EPM episode
• Part B services not likely related to care provided during EPM episode
• Drugs outside of EPM definitions (hemophilia clotting factors)
• IPPS new technology add‐on payments for drugs, technologies & services
• OPPS transitional pass‐through payments for medical devices
SCOPE OF EPM SERVICES & ITEMS
Hospitals are financially accountable for all related Part A & B claims that occur during episode, significant amount of which fall in post‐acute phase
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• EPMs will operate under retrospective & two‐sided risk modelwith hospitals bearing financial responsibility Hospitals & other providers will be paid under FFS, per usual
Reconciliation process will be performed at end of each EPM performance year where hospital’s financial performance will be compared against quality‐adjusted target price
• If hospital’s spending exceeds target price, repayment is owed to CMS
• If hospital’s spending is less than target price, reconciliation payment will be paid to hospital from CMS
EPM FINANCIAL ACCOUNTABILITY
CMS gets their cut –
$50M total CMS savings during five‐year cardiac bundles
HOSPITAL SELECTION
Using random selection, three MSA groups were chosen1. AMI/CABG
• 98 MSAs• 1,127 hospitals
2. CJR/SHFFT• 67 MSAs• CJR = 792 hospitals*• SHFFT = 866 hospitals
3. AMI/CABG/CJR/SHFFT• 17 MSAs• 195 hospitals
• AMI & CABG are implemented in same MSAs
• SHFFT is implemented in same MSAs as CJR, mostly to same providers
98 AMI/CABG
MSAs
*CJR providers list updated January 1, 2017
148 out of 374 MSAs, or 40% of MSAs, are subject to mandatory bundles
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• AMI/CABG beneficiaries have more chronic diseases
• AMI/CABG beneficiaries have higher rates of mortality & readmissions
• AMI episodes require different clinical pathways (medical, interventional) & have
greater variation in these pathways
• AMI episodes are emergent cases
• Hospitals may not offer all services required to treat AMI
• Three‐fourths of CABG episode spending occurs in acute‐care phase
CARDIAC BUNDLE CHALLENGES COMPARED TO CJR
Compared to CJR, EPM beneficiaries will be more complex to care for & higher in acuity
• Protocol development
• Standardization of care pathways
HOW TO WORK WITH PHYSICIANS TO MANAGE RISK
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EPM FINAL RULING – KEY ELEMENTS
• Major changes from proposed rule
• Transfer policies
• Composite quality score
• EPM benchmark prices
• How reconciliation & repayments are calculated
• EPM collaborators & gainsharing
• EPM waivers
• Cardiac Rehabilitation Incentive Model
KEY ELEMENTS OUTLINE
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• Delayed downside risk by one year EPM participants will not have mandatory downside risk until episodes starting January 1, 2019. Optional downside
risk is available starting January 1, 2018
• Eliminated chained‐anchor hospitalizations transfer scenario Hospitals that transfer EPM beneficiary to another hospital during anchor hospitalization will result in canceled
episode (if applicable) for initial hospital
• New voluntary CABG quality metric STS CABG composite score
• Cancels EPM episode if beneficiary dies during episode Originally CMS only canceled episode if death occurred during anchor stay
• Greater protections for low‐volume hospitals Created “EPM‐volume protection hospitals” category (hospitals where historical EPM volume is at or below 10th
percentile of all hospitals in same MSA eligible to be in that EPM), who will have same lower stop‐loss limits as rural hospitals, SCHs, MDHs & RRCs
• Waived definition of “qualified physician” for cardiac rehab model Nonphysician practitioners (PA, NP, CNS) are now qualified for specific functions
• More flexibility to use CR incentive payments May use CR incentive payments to provide beneficiaries with more than just transportation
MAJOR CHANGES FROM PROPOSED RULE
Scenario Episode Initiation & Attribution Policy
No transfer (participant)• Initiate AMI of CABG episode based on anchor hospitalization
MS‐DRG• Attribute episode to initial treating hospital
No transfer (nonparticipant) • No AMI or CABG episode initiated
Inpatient to inpatient(i‐i) transfer (nonparticipant to participant)
• Initiate AMI or CABG episode based on MS‐DRG at i‐i transfer hospital
• Attribute episode to i‐i transfer hospital
Inpatient to inpatient transfer (participant to nonparticipant)
• Cancel AMI episode• No other AMI or CABG episode is initiated
Inpatient to inpatient transfer(participant to participant)
• Cancel AMI episode at initial treating hospital. Initiate AMI or CABG episode at i‐i transfer hospital
• Attribute episode to i‐i transfer hospital
Outpatient to inpatient (o‐i)transfer (nonparticipant to participant or participant to participant)
• Initiate AMI or CABG episode based on anchor hospitalization MS‐DRG at o‐i transfer hospital
• Attribute episode to the o‐i transfer hospital
Outpatient to inpatient transfer(participant to nonparticipant)
• No AMI or CABG episode is initiated
TRANSFER POLICY SUMMARY
If participant hospital does not admit or discharge beneficiary, episode will not occur
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COMPOSITE QUALITY SCORE OVERVIEW
AMI1. MORT–30–AMI: hospital 30‐day, all‐cause, risk‐standardized mortality rate (RSMR) following acute myocardial infarction (NQF #0230)
2. AMI excess days: excess days in acute care after hospitalization for AMI (includes Emergency Department observation & inpatient readmission)
3. HCAHPS survey: hospital consumer assessment of health care providers & systems (NQF #0166)
4. Hybrid AMI mortality (voluntary submission): hybrid hospital 30‐Day, all‐cause, risk‐standardized mortality rate following acute myocardial infarction hospitalization (NQF #2473)
CABG1. MORT–30–CABG: hospital 30‐day, all‐cause, risk‐standardized mortality rate (RSMR) following coronary artery bypass graft (CABG) surgery (NQF# 2558)
2. HCAHPS survey: hospital consumer assessment of health care providers & systems (NQF #0166)
3. STS Composite CABG (voluntary submission): Multidimensional performance measure that assesses surgical performance based on a combination of 11 NQF‐endorsed CABG process & outcomes measures (NQF #0696)
AMI COMPOSITE QUALITY SCORE CALCULATIONPercentile
30‐Day Mortality (+1 for improvement)
AMI Excess Days(+0.4 for improvement)
HCAHPS(+0.4 for improvement)
Hybrid AMI Mortality (Voluntary)
WEIGHT 50% 20% 20% 10%
≥90th 10.00 4.00 4.00
Two points awarded for successful submission
≥80th & <90th 9.25 3.70 3.70
≥70th & < 80th 8.50 3.40 3.40
≥60th & <70th 7.75 3.10 3.10
≥50th & <60th 7.00 2.80 2.80
≥40th & <50th 6.25 2.50 2.50
≥30th & <40th 5.50 2.20 2.20
<30th 0.00 0.00 0.00
• Composite quality score = 13.2 quality category = good
• Successful submission of voluntary data would have resulted in composite score of 15.2 & placed them in excellent category
<3.8 >=3.8 & <6.3 >=6.3 & <=15.0 >15.0
<=3.7 >3.7 & <=6.25 >6.25 & <=15.0 >15.0
Shrank Grew Grew No change
Max 20 pts
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• Hybrid AMI Mortality Voluntary Data requires five key clinical data elements from the EHR
1. Age
2. Heart rate
3. Systolic blood pressure
4. Troponin
5. Creatinine
• Missing troponin will not result in unsuccessful submission for PY1
Will need to indicate that it was not drawn within first 24 hours
• Also need to submit six additional linking variables (CCN, HIC Number, date of birth, sex, admission date & discharge date)
HYBRID AMI MORTALITY MEASURE DETAILS
PY AMI Voluntary Measure Successful Submission Requirements
2017 At least 50% of qualifying hospitalizations
2018–2021 At least 90% of qualifying hospitalizations
First captured, measured within two hours of presentation to hospital
First captured, measured within 24 hours of presentation to hospital
• Composite quality score = 13.2 quality category = good
• Successful submission of voluntary data would have resulted in composite score of 15.2 & not have affected their quality category
Percentile30‐Day Mortality
(+1.4 for improvement)HCAHPS Survey
(+0.4 for improvement)STS Composite CABG
(Voluntary)
WEIGHT in Composite Score 70% 20% 10%
≥90th 14.00 4.00
Two points awarded for successful submission
≥80th & <90th 12.95 3.70
≥70th & < 80th 11.90 3.40
≥60th & <70th 10.85 3.10
≥50th & <60th 9.80 2.80
≥40th & <50th 8.75 2.50
≥30th & <40th 7.70 2.20
<30th 0 0
CABG COMPOSITE QUALITY SCORE CALCULATION
<2.2 >2.2 & <=3.4 >3.4 & <=16.2 >16.2
Grew Shrank Shrank No change
Below Acceptable
<2.5 >=2.5 & <3.5 >=3.5 & <=16.2 >16.2
Max 20 pts
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QUALITY MEASURE SUBMISSION DATES
PY 1 (2017) PY 2 (2018) PY 3 (2019) PY 4 (2020) PY 5 (2021)
MORT‐30‐AMI
July 1, 2014–June 30, 2017
July 1, 2015–June 30, 2018
July 1, 2016–June 30, 2019
July 1, 2017–June 30, 2020
July 1, 2018–June 30, 2021
AMI ExcessDays
MORT‐30‐CABG
HCAHPSJuly 1, 2016–June 30, 2017
July 1, 2017–June 30, 2018
July 1, 2018–June 30, 2019
July 1, 2019–June 30, 2020
July 1, 2020–June 30, 2021
Voluntary AMI & CABG measures
July 1, 2017–August 31, 2017
September 1 2017 –June 30, 2018
July 1 2018 –June 30, 2019
July 1 2019 –June 30, 2020
July 1, 2020 –June 30, 2021
Poor quality scores can affect your composite quality score three years later, thus impacting your payment amounts
WHY QUALITY MATTERS
Effective Discount Factors for Reconciliation Effective Discount Factors for Repayment
Quality Score 2017 2018 2019 2020 2021 Quality Score 20172018
(Voluntary) 2019 2020 2021
Below Acceptable N/A N/A N/A N/A N/A
Below Acceptable N/A 2.0% 2.0% 3.0% 3.0%
Acceptable 3.0% 3.0% 3.0% 3.0% 3.0% Acceptable N/A 2.0% 2.0% 3.0% 3.0%
Good 2.0% 2.0% 2.0% 2.0% 2.0% Good N/A 1.0% 1.0% 2.0% 2.0%
Excellent 1.5% 1.5% 1.5% 1.5% 1.5% Excellent N/A 0.5% 0.5% 1.5% 1.5%
• Quality category translates into effective discount factors
• No financial reward for below acceptable quality
Composite quality score Effective discount factor
Higher reconciliation payments from CMS or
lower repayment amount owed to CMS
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• Sharing performance & outcome results
• Accurate coding of clinical & quality metrics
• Physician engagement
HOW TO WORK WITH PHYSICIANS TO MANAGE RISK
EPM FINANCIALS GLOSSARY & GUIDELINES
• Prices will be set with exclusion of special payments (DSH, IME, etc.)• High payments will still be capped at two standard deviations above regional mean before calculating NPRA
•Dollar amount assigned to EPM episode (based on blend of historical & regional data) prior to application of effective discount factorBenchmark price
•Discount factor established by EPM participant’s quality category (3% maximum CMS savings)Effective discount factor
•Benchmark price × effective discount factorQuality‐adjusted target price
•Quality‐adjusted target price ‐ actual episode spendNet Payment Reconciliation Amount (NPRA)
•Maximum reconciliation payment
•Limit % × quality‐adjusted target price × number of episodesStop‐gain limit
•Maximum repayment amount
•Limit % × quality‐adjusted target price × number of episodesStop‐loss limit
•Dollar amount received from CMS if NPRA is positive
•If NPRA < stop‐gain limit, then = NPRA
•If NPRA > stop‐gain limit, then = stop‐gain limitReconciliation payment
•Dollar amount owed to CMS if NPRA is negative
•If NPRA < stop‐loss limit, then = stop‐loss limit
•If NPRA > stop‐loss limit, then = NPRARepayment amount
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AMI PRICING SCENARIO Episode Benchmark Price
Single AMI or PCI MS‐DRG (with AMI dx) Standard episode benchmark price based on anchor MS‐DRG
AMI or PCI MS‐DRG (with AMI dx) with CABGreadmission
Standard episode benchmark price of AMI anchor MS‐DRG + CABG anchorhospitalization benchmark price corresponding to CABG readmission MS‐DRG
Single hospital CABG MS‐DRG with AMIdiagnosis
CABG anchor hospitalization benchmark price for MS‐DRG + CABG post‐anchorhospitalization benchmark price based on presence of AMI ICD‐CM diagnosis code & whether anchor MS‐DRG is with MCC or without MCC
Single hospital CABG MS‐DRG without AMIdiagnosis
CABG anchor hospitalization benchmark price for MS‐DRG + CABG post‐anchorhospitalization benchmark price based on no AMI ICD‐CM diagnosis code & whetheranchor MS‐DRG is with MCC or without MCC
BENCHMARK PRICES SET BY MS‐DRG WITH ADJUSTMENTS
Limited risk‐stratification in setting benchmark prices to allow for additional spending for CABG beneficiaries with AMI & with MCC
• Region is defined as U.S. census regions
• Competing against your own historical performance at the beginning, then that of the region’s at the end
BENCHMARK PRICES SET BY HOSPITAL & REGION PERFORMANCE
PY 1 & 2
(2017 & 2018)
•2/3 Hospital
•1/3 Regional
PY 3 (2019)
•1/3 Hospital
•2/3 Regional
PY 4 & 5
(2020 & 2021)
•100% Regional
2013–2015 Historical Data 2017–2019 Historical Data2015–2017 Historical Data
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STOP‐GAIN/LOSS LIMITS & PROTECTION FOR SMALL HOSPITALS
2017 2018 2019 2020 2021
Stop‐Gain Limit 5.0% 5.0% 5.0% 10.0% 20.0%
Stop‐Loss Limit N/A 5.0% (voluntary) 5.0% 10.0% 20.0%
Stop‐Loss Limit for Certain Hospitals* N/A N/A 3.0% 5.0% 5.0%*Rural hospitals, SCHs, MDHs, RRCs & EPM low‐volume protection hospitals
• CMS will cap reconciliation payments & repayments by stop‐loss & stop‐gain limits
• Lower stop‐loss limits for smaller hospitals
• Calculated as percentage of aggregated quality‐adjusted target price
• No. 1 Hospital
Benchmark price for MS‐DRG 280: $24,000
Effective discount factor (acceptable category): 3%
• CMS savings = $720
Quality‐adjusted benchmark price: ($24,000‐($24,000×3%)) = $23,280
Actual episode spend: $22,000 & $28,000
NPRA
• Jane Doe: $1,280
• John Smith: ‐$4,720
• Total: ‐$3,440
Stop‐loss limit (assuming PY3)
• ($23,280×2 episodes)×5% = $2,328
Repayment amount: ‐$2,328
EPM RECONCILIATION EXAMPLE
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EPM RECONCILIATION EXAMPLE: IMPACT OF QUALITY
No. 1 Hospital No. 2 Hospital
• Quality category Acceptable
• Effective discount factor 3%
• Quality‐adjusted target price $23,280
• NPRA ‐$120
• Owes repayment to CMS
• Quality category Excellent
• Effective discount factor 1.5%
• Quality‐adjusted target price $23,640
• NPRA $240
• Receives reconciliation payment from CMS
Above quality‐adjusted
target price
Below quality‐adjusted
target price
Quality category can determine whether participant hospital makes or owes money
For example, two hospitals have same benchmark price & episode spend
• Collaborators can be1. SNF2. HHA3. LTCH4. IRF5. Physician6. Nonphysician practitioner7. Therapist in private practice8. CORF9. Provider of outpatient therapy services10.PGP11. Hospital12. CAH13. NPPGP14. TGP15. ACO
EPM COLLABORATORS & GAINSHARING• Hospitals can enter into financial arrangements with collaborators, subject to the following
Written sharing agreement must be established prior to sharing financial risk & gain
Collaborators must provide billable item or service to EPM beneficiary during EPM
Gainsharing arrangements must be based on quality metrics set by hospital, & never on volume of current & future referrals
Hospital may only share reconciliation payments or internal cost savings
Hospitals must pay at least 50% of repayment risk & single collaborator may pay max 25%
Total payment to collaborators from hospitals must not exceed total reconciliation amount
Hospitals may recommend preferred providers, but may not restrict beneficiaries’ choice. Collaborations must be disclosed to beneficiary
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EPM WAIVERS
Only waived for AMI episodes beginning October 4, 2018
Medicare will cover SNF stay if patient is discharged from inpatient stay in less than three days
SNF must have at least three‐star rating for seven out of last 12 months
Hospitals that elect early downside risk in PY2 are not eligible for early waiver
SNF three‐day rule For EPM beneficiaries who
would otherwise not qualify for home health, e.g., not homebound, waiver allows them to receive home health visits
Nonphysician practitioners may provide visits
AMI EPM beneficiaries may receive maximum of 13 visits
CABG & SHFFT EPM beneficiaries may receive maximum of nine visits
Home visits Waives the rural & other
geographic requirements so that all EPM beneficiaries may receive telehealth
Beneficiaries may receive visits while at home
Service must be Medicare‐approved telehealth service with ICD‐10 code that is not excluded from EPM episode definition
Tele‐health waiver
• Aim is to increase utilization of cardiac rehab (CR) or intensive cardiac rehab (ICR) for beneficiaries in AMI &/or CABG EPMs
• Research has proven that CR utilization led to improved outcomes
Reduced cardiovascular mortality• More significant for patients who received 11 or more sessions
Improved health‐related quality of life
Reduced risk of hospital readmission
• CR/ICR services do not need to be provided by CR participant in order for them to receive incentive
CARDIAC REHABILITATION INCENTIVE PAYMENT MODEL
$25/ session
$175/ session
$4,650
total available incentive*
First 11 sessions
Subsequent sessions during episode
*Assumes current limitations on number of covered cardiac rehab sessions to two one-hour sessions per day, for a total of 36 sessions over 36 weeks
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Random selection resulted in
• 45 MSAs in EPM –EPM‐CR
• 45 MSAs in FFS –FS‐CR
Still qualified for AMI/CABG MSA selection
• 1,173 providers
CR PROVIDER SELECTION
90 CR MSAs
• CMS waived definition of physician to include nonphysician practitioner (except for medical director) Physician assistant Nurse practitioner Clinical nurse specialist
• Nonphysician practitioner may perform functions of supervisory physician Prescribing exercise Establishing, reviewing & signing
individualized treatment plan for provider or supplier of CR & ICR services furnished to EPM beneficiary during AMI or CABG episode
WAIVER & INCENTIVES TO INCREASE ACCESS TO CRPhysician Definition Waiver Beneficiary Incentives
• May provide engagement incentives to beneficiaries in AMI care period or CABG care period under CR incentive payment model
Same rules as beneficiary incentives for EPMs
CMS recommends using incentives towards providing transportation
Hospitals cannot pay for or subsidize patient’s co‐pay for CR
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• Post‐discharge communication & coordination
• Increase cardiac rehabilitation referrals & utilization
HOW TO WORK WITH PHYSICIANS TO MANAGE RISK
IMPLICATIONS & NEXT STEPS
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1. Increasing post‐hospitalization follow‐up & medical management for patients
2. Coordinating across inpatient & post‐acute care spectrum3. Conducting appropriate discharge planning4. Improving adherence to treatment or drug regimens5. Reducing readmissions & complications during post‐discharge period6. Managing chronic diseases & conditions that may be related to EPM
episodes7. Choosing most appropriate post‐acute care setting8. Coordinating between providers & suppliers such as hospitals, physicians &
post‐acute care providers
APPROPRIATE STRATEGIES FOR CARE REDESIGN
• Analyze your data Identify your high‐cost areas Identify variations in process Benchmark yourself against evidence‐
based practices & high performers Create preferred providers list
• Identify a physician champion & build a team
• Develop relationships with post‐acute providers
• Develop risk assessment tool & system that works for you
• Educate your staff & get their input & buy‐in
RECOMMENDATIONS
CMS is planning to make historical data & benchmark prices available by midspring to CR & EPM participants
Physician 1
Physician 2
Physician 3
Physician 4
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QUESTIONS?
CONTINUING PROFESSIONAL EDUCATION (CPE) CREDITS
BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org
The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered
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• CPE credit may be awarded upon verification of participant attendance
• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]
CPE CREDIT
THANK YOU!FOR MORE INFORMATION
Eric Rogers | 417.865.8701 | [email protected]
Lucy Zhang | 314.231.5544 | [email protected]
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