advancing care coordination proposed rule

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Advancing Care Coordination

Proposed RuleReleased July 25, 2016

Erin Smith, JD

VP and Executive Director, PACCR

Jourdan Meltzer

Research Associate, PACCR

August 4, 2016

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Three new mandatory Episode Payment Models (EPMs)

• Episode definition: AMI, CABG, & SHFFT

• Payment: Risk-bearing, benchmarking, quality, & overall financial arrangement

• Patterns of care

• Opportunities for savings

Cardiac Rehabilitation (CR) Incentive Payment Model

• Incentive payment structure

Changes to CJR

• MACRA & pathway to Advanced APM qualification

• Projected BPCI updates

Presentation Overview

paccr.org

Episode Payment Models

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CMS proposed three new EPMs

• Acute myocardial infarction (AMI)

• Coronary artery bypass graft (CABG)

• Surgical hip/femur fracture treatment excluding lower extremity joint replacement (SHFFT)

Cardiac (AMI & CABG) EPMs will be mandatory in 98 randomly selected metropolitan statistical

areas (MSAs TBD)

SHFFT EPM will be an expansion of CJR and include the same 67 MSAs

Proposed start – July 1, 2017

5-year model – ending December 31, 2021

Overview: Three New Episode-Based Payment Models (EPMs)

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Initiates upon a hospital inpatient admission and extends through 90 days post-discharge

Episode Definition

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

AMI Episodes

• Acute myocardial infarction

• AMI admissions treated with medical management

• MS-DRGs 280-282

• AMI admissions treated with PCI

• MS-DRGs 246-251 with AMI ICD-CM diagnosis code

CABG Episodes

• Coronary artery bypass graft admissions for coronary revascularization irrespective of AMI diagnosis

• MS-DRGs 231-236

SHFFT Episodes

• Surgical hip/femur fracture treatment procedures excluding lower extremity joint replacement

• MS-DRGs 480-482

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Regular Medicare FFS payments throughout the model

Retrospective payment model – after episode ends the episode payment will be calculated based on Medicare claims data and reconciled against established EPM quality-adjusted target price

Phased-In Risk: no downside risk PY 1 and increasing upside and downside risk

Episode Payment Calculation & Risk Bearing

Upside Gains: capped at 5%

Downside Lossesno repayment

Upside Gains capped at 5%

Downside Losses capped at 5%

Upside Gains capped at 10%

Downside Losses capped at 10%

Upside Gains capped at 20%

Downside Losses capped at 20%

PY 1 – Q1 PY 2Jul 2017–Mar 2018

Q2 – 4 PY 2 Apr 2018–Dec 2018

PY 3Jan 2019–Dec 2019

PY 4 & 5Jan 2020–Dec 2021

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Target prices will be based on blend of regional- and participant-specific data, with increasing proportion of regional data over time

• Proposal to use the 9 U.S. Census Regions

Target Price: Benchmarking

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

PY 1 & 2 July 2017–Dec 2018

PY 3Jan 2019–Dec 2019

PY 4 & 5Jan 2020–Dec 2021

RH

RH

R

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Composite quality score to assign EPM participants to four quality categories

Only EPM participants that achieve quality category of "acceptable" or higher will be eligible for a reconciliation payment

Quality Component

AMI

• MORT-30-AMI: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following AMI Hospitalization (NQF #0230)

• AMI Excess Days: Excess Days in Acute Care after Hospitalization for AMI

• HCAPHS Survey (NQF #0166)

• Voluntary Hybrid Hospital 30-Day, All-Cause, Risk-Standardized Mortality eMeasure (NQF #2473) data submission

CABG

• MORT-30-CABG: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG (NQF #2558)

• HCAPHS Survey (NQF #0166)

SHFFT

• Same measures as CJR:

• Hospital-Level Risk-Standardized Complication Rate Following Elective Primary THA and/or TKA (NQF #1550)

• Successful Voluntary Reporting of Patient-Reported Outcomes and Limited Risk Variable data submission

• HCAPHS Survey (NQF #0166)

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Quality Category Eligible for Reconciliation

Payment

Effective Discount % for

Reconciliation Payment

Effective Discount % for Repayment

Amt.

Excellent Yes 1.5% N/A

Good Yes 2.0% N/A

Acceptable Yes 3.0% N/A

Below Acceptable No 3.0% N/A

Payment Eligibility and Repayment Responsibility: Performance Year 1 & Quarter 1 of Performance Year 2

PY 1 & Q1 PY 2

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

Downside risk/ repayment begins being

phased in Q2 of PY 2

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Quality Category Eligible for Reconciliation

Payment

Effective Discount % for

Reconciliation Payment

Effective Discount % for Repayment

Amt.

Excellent Yes 1.5% 0.5%

Good Yes 2.0% 1.0%

Acceptable Yes 3.0% 2.0%

Below Acceptable No 3.0% 2.0%

Payment Eligibility and Repayment Responsibility: Quarters 2-4 of Performance Year 2 & Performance Year 3

Q2-4 PY 2 & PY 3

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

Downside risk/ repayment begins

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Quality Category Eligible for Reconciliation

Payment

Effective Discount % for Reconciliation

Payment

Effective Discount % for Repayment Amt.

Excellent Yes 1.5% 1.5%

Good Yes 2.0% 2.0%

Acceptable Yes 3.0% 3.0%

Below Acceptable No 3.0% 3.0%

Payment Eligibility and Repayment Responsibility: Performance Years 4 & 5

PYs 4 & 5

Discount increases by 1% for all categories

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Gainsharing Eligibility

• Must meet the criteria set by participating hospital

• Physicians, NPPs, and PGPs must furnish a billable service in an episode

Gainsharing and Risk Sharing

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

EPM Collaborators• SNF• HHA• LTCH• IRF• PGP• Physician• Nonphysician practitioner• Provider/supplier of

outpatient therapy services

• ACOs• Hospitals• CAHs

EPM hospitals may share reconciliation payments and repayment risk with collaborators

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Proposed EPM Financial Arrangements

Physician or NonphysicianPractitioner

SNF, HHA, LTCH, IRF, Hospital, CAH, Provider/ Supplier of OP Therapy Services

ACO Provider/Supplier (e.g., Physician)

ACO Participant: Other

Physician or NPP (PGP Member)

Physician or NPP (PGP Member)

Gai

nsh

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Paym

ents

(+

)

Alig

nm

ent

Paym

ents

(-

)

ACO PGP

Do

wn

stre

am

Dis

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P

aym

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ACO Participant: PGP

CMS

EPM Participants

Reconciliation Payments (+)Repayment Amounts (-)

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Limits on Gainsharing and Risk Sharing

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

50%

25%

20%

5%

EXAMPLE SHARING ARRANGEMENT

Participant Hospital

Collaborator 1 (HHA)

Collaborator 2 (SNF)

Collaborator 3 (PGP)

• Participant hospitals may share reconciliation payments and internal cost savings

• Individual physicians/practitioners gainsharing payments are capped at 50% of their PFS payments for episode services

• PGPs may receive gainsharing payments up to 50% of their PFS payments for episode services

Gainsharing Payments

• Participant hospitals may share repayment responsibilities

• Hospital must retain responsibility for retaining 50% of the repayment amount

• A single collaborator that is not an ACO may not pay more than 25% of the repayment amount

• ACO collaborators may pay up to 50% of the repayment amount

Alignment Payments

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Payment Policy WaiversSNF 3-day Stay

• AMI only

• Not applicable for CABG or SHFTT episodes

• Allows coverage of a SNF stay following discharge from an anchor CJR hospital stay of less than 3 days

• SNF must have 3 star or better rating

• Beginning April 1, 2018

Home Visits

• Waives supervision requirement so that clinical staff may provide home visits under general supervision

• AMI – up to 13 home visits in the 90 days

• CABG – up to 9 home visits in the 90 days

• SHFFT – up to 9 home visits in the 90 days

• Waive global period restrictions to allow for home visits

Telehealth

• Waives the geographic site requirement and the originating site requirement for telehealth services

• Telehealth services may be provided in a CJR beneficiary’s home or residence

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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LEJR in CJR is predominantly elective, has rare hospital readmissions, & commonly substantial post-acute care provider utilization none of which are characteristics of AMI or CABG

AMI, CABG, & SHFFT EPMs all encompass chronic conditions that require both planned and unplanned care

AMI model as important next step for testing EPMs for clinical conditions with variety of different approaches to treatment and management• Single clinical condition with substantially different clinical care

pathways: medical management and PCI

Patterns of Care: Contrast to LEJR Episode in CJR

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Understanding historical spending patterns for the three high-expenditure, common episodes selected with their significant spending variation in mind

Opportunities for Savings

AMI Model

• ~50% of spending on initial hospitalization

• Majority of post-discharge spending is for readmissions

• Lesser spending for SNFs, Part B professional services, & hospital outpatient

CABG Model

• ~75% of spending on initial hospitalization.

• Post-discharge spending is evenly distributed among Part B professional services & hospital readmissions.

• Most patients are discharged to SNFs

SHFFT Episodes

• Substantial readmissions

• High use of PAC services

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

paccr.org

Cardiac Rehabilitation Incentive Payment Model

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Direct financial incentives for hospitals treating AMI or CABG beneficiaries to encourage care coordination and greater utilization of medically necessary CR/ICR services in the 90 days post-discharge.

45 MSAs from the AMI and CABG EPMs.

45 MSAs with regular Medicare payments.

CR/ICR seen as underutilized way to improved long-term patient outcomes.

•Focus: increased utilization of CR/ICR services alone, payment NOT tied to quality and efficiency.

Overview: Cardiac Rehabilitation (CR) Incentive Payment Model

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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• Within a single AMI or CABG model episode or AMI or CABG care period:

• $25 per service

First 11 CR/ICR

Services

• Within a single AMI or CABG model episode or AMI or CABG care period:

• $175 per service

After 11 CR/ICR

Services

CR Incentive Payment Structure

Determination:

Number of CR/ICR services -counted on OPPS and PFS paid claims

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Cardiac Rehabilitation (CR) Intensive Cardiac Rehabilitation (ICR)

Examples: exercise training, education on heart healthy living, counseling to reduce stress, etc.

Example: similar services to CR provided more rigorously and frequentlyICR program must illustrate within peer-reviewed, published research that it 1). a). positively affects the progression of coronary heart disease, b). reduces the need for CABG, or c). reduces the need for PCI, and 2). makes a statistically significant reduction in one or more of the following six measures: low density lipoprotein, triglycerides, BMI, systolic blood pressure, diastolic blood pressure, & need for cholesterol, blood pressure, and diabetes medications, in order to receive CMS approval.

Two one-hour sessions/day Six one-hour sessions/day

For a total of 36 sessions total over 36 weeks For a total of 72 sessions total over 18 weeks

Maximum Services

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CR Incentive Payments cannot be included in gain-sharing arrangements.

Understanding depth of impact:• CR incentive model impact of Medicare program: 2017 – 2024 range of

$27 million in spending to $32 million in savings.

• HUGE range dependent on change in utilization of CR/ICR services under the incentive program.

Limitations

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

paccr.org

CJR Refinements

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Creation of two separate tracks, Track 1 and Track 2, where Track 1 would create a pathway to qualification as Advanced APM.• Track 1 has CEHRT requirement.

• Opens possibility for similar pathway for BPCI to meet Advanced APM criteria.

Technical changes for quality scoring effect on reconciliation payments.

Overview: CJR Updates

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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MACRA Background: Advanced APMs under the QPP

Must meet qualifying thresholds for seeing statistically significant amount of Medicare patients within the APM or receiving statistically significant payment for services through the APM.

Qualify as group

• All eligible clinicians in Advanced APM Entity become QPs for payment year.

Criteria for Advanced APMs

•APM requires participants to use certified EHR technology.

Certified EHR Use

•APM bases payment on quality measures comparable to those in the MIPS quality performance category.

Quality Measures

•APM entities bear more than nominal financial risk for monetary losses, OR:

•APM is a medical home expanded under CMMI authority.

Financial Risk

In APM with Advanced APM

Designation

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Fitting in with larger contexts of MACRA and Advanced APMs.

In Track 1 CJR and its participant hospitals will meet criteria for Advanced APMs as proposed in Quality Payment Program in the MACRA proposed rule.

Biggest change to be consistent with qualifying standards for Advanced APMs is CEHR requirement for CJR Track 1.

Creation of Track 1 and Track 2: CEHR Requirement

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Stronger connection & alignment with quality scoring of other CMS programs.

Reducing threshold for defining quality measure improvement from 3 deciles to 2 deciles ultimately increasing number of CJR participant hospitals eligible for quality improvement points.

Awarding up to 10% of maximum measure performance score on certain measures and imposing a cap on composite quality score at 20 points.

Technical term change: “episode target price” to “quality-adjusted target price.”

Quality Alignment with Language and Directives of MACRA

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

paccr.org

Looking Forward

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EPMs aren’t just for hospitals

BPCI 2.0 is planned for 2018 onwards• Adapted version of BPCI?

• Expanded version of BPCI?

Voluntary models and mandatory models can coexist – not either/or

Projected BPCI Updates

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Driving towards the HHS goal of tying 50% of FFS payments to Alternative Payment Models.• High-level: episode payment models, ACOs, and advanced primary care.• While we see similarities to CJR, don’t assume that this is the new norm.• Seeking new approaches to episode payments for

conditions/procedures that do not fit into this model.

Expanding opportunities for MACRA incentives for Advanced APMs.• New options to create pathways for qualifications.

Expecting a final rule on new models this fall.

Takeaways

Connect with PACCR!

@PAC_CR

Post-Acute Care Center for Research (PACCR)

paccr@paccr.org

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Appendix 1: Measures and Associated Performance Weights in Composite Quality Score

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

Model Quality Measure Weight in Composite Quality Score Quality Domain/Weight

MORT-30-AMI (NQF #0230) 50%

AMI Excess Days 20% Outcome/ 80%

AMI Model Hybrid AMI Mortality (NQF #2473) Voluntary Data

10%

HCAHPS Survey (NQF #0166) 20% Patient Experience/ 20%

CABG ModelMORT-30-CABG (NQF #2558) 75% Outcome/ 75%

HCAHPS Survey (NQF #0166) 25% Patient Experience/ 25%

Hip/Knee Complications (NQF #1550

50% Outcome/ 50%

SHFFT Model THA/TKA voluntary PRO and limited risk variable submission

10%Patient Experience/ 50%

HCAHPS Survey (NQF #0166) 40%

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Performance Percentile MORT-30-AMI(Points)

AMI Excess Days(Points)

HCAHPSSurvey(Points)

≥90th 10.00 4.00 4.00

≥80th and <90th 9.25 3.70 3.70

≥70th and <80th 8.50 3.40 3.40

≥60th and <70th 7.75 3.10 3.10

≥50th and <60th 7.00 2.80 2.80

≥50th and <50th 6.25 2.50 2.50

≥30th and <40th 5.50 2.20 2.20

<30th 0.00 0.00 0.00

Appendix 2: Individual Measure Performance ScoringFor Three Required AMI Quality Measures

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

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Appendix 3: Individual Measure Performance ScoringFor Two Required CABG Quality Measures

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

Performance Percentile MORT-30-CABG(Points)

HCAHPSSurvey(Points)

≥90th 15.00 5.00

≥80th and <90th 13.88 4.63

≥70th and <80th 12.75 4.25

≥60th and <70th 11.63 3.88

≥50th and <60th 10.50 3.50

≥50th and <50th 9.38 3.13

≥30th and <40th 8.25 2.75

<30th 0.00 0.00

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Appendix 4:Individual Measure Performance ScoringFor Two Required SHFFT Quality Measures

Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P)

Performance Percentile Hip/Knee Complications(Points)

HCAHPSSurvey Quality Score

(Points)

≥90th 10.00 8.00

≥80th and <90th 9.25 7.40

≥70th and <80th 8.50 6.80

≥60th and <70th 7.75 6.20

≥50th and <60th 7.00 5.60

≥50th and <50th 6.25 5.00

≥30th and <40th 5.50 4.40

<30th 0.00 0.00