the changing apm landscape: opportunities and challenges20% 15% 10% 60% 55% 40% 20% 30% 50% 2014...
TRANSCRIPT
The Changing APM Landscape: Opportunities and ChallengesPamela M. Pelizzari, MPH, MillimanErin Smith, JD, naviHealth
Agenda
Key pressures for CMS• 2018 Goal of 50% of FFS payments through APMs• MACRA – opportunities for physicians to participant• Demonstrating success – nearing a decade post-ACA Case study: Advanced BPCI • Expectations • What’s this say about the future of bundled payment modelsDeveloping new APMs• Key financial analyses• Operational challenges
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Key Pressures for CMS
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20% 15% 10%
60% 55%40%
20% 30% 50%
2014 2016 2018
Traditional FFS Payments
FFS Linked to Quality or Value
FFS Paid Through APMs
HHS Timeline for Transition to Value (% Medicare Payments)
HHS goals for shifting from volume to value
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ES1ES3
Slide 4
ES1 These percentages all add up to 100%, but they aren't the same size. it's kind of confusing. Also these are the percentages for linking payment to value or quality.Erin Smith, 5/9/2016
ES3 From HHS: "HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or valuethrough alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs."Erin Smith, 5/9/2016
MACRA Implementation
MACRA incentivizes physicians to join Advanced Alternative Payment Models (Advanced APMs)• Avoid downward payment adjustments from MIPS• Earn a 5% lump sum incentive payment for 5 years• Receive larger physician fee schedule updates• Reduced burden of reporting for MIPSHowever, there are only a small number of advanced APMs currently available
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Advanced APMs
2017 – Confirmed Advanced APMs
• Comprehensive Primary Care Plus• Comprehensive ESRD Care Model –
LDO arrangement and non-LDO two-sided risk arrangement
• Next Generation ACO Model• Oncology Care Model – two-sided
risk arrangement• Medicare Shared Savings Program
ACO – Tracks 2 and 3
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2018 – Expected Additions
• Comprehensive Care for Joint Replacement – Track 1
• Episode Payment Models – Track 1• Medicare Shared Savings Program
ACO Track 1+• New voluntary BPCI-like Model
Advanced BPCI
Next phase of BPCI
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CMS intends to continue BPCI-like voluntary models
“[B]uilding on the BPCI initiative, the Innovation Center intends to implement a new voluntary bundled payment model for CY 2018 where the model(s) would be designed to meet the criteria to be an Advanced APM.” - Advancing Care Coordination Through Episode Payment Models (EPMs) Proposed Rule (81 FR 50810)
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Expected to be a graduation from BPCI Classic
• Looking to ACOs as an example –Next Gen allows new opportunities for Pioneer ACOs
• CMS will not want to appear as if penalizing early adopters
• CMS wants to hold on to participants and gain new ones
Voluntary models must provide strong incentives to participate
Required to either expand the model (with certification from OACT) or test a new payment model
Expectations for Advanced BPCI
• Participationo Multiple provider types may participateo Voluntary = no rulemaking
• Streamline model options – Models 1 and 4 will not be included • Continue with complete cost of care models, include everything unless
specific exception – similar to BPCI Classic • Continue current risk bearing structure – w/ convener and episode initiator • Advanced model will be open to new participants • Longer performance periods – shifting away from quarterly recon period • Target prices prospectively • Advanced APM
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Potential transition timeframe to Advanced BPCI
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Sept 30, 2018BPCI Classic participation ends Oct 1, 2018
Advanced BPCI participation begins
Fall 2017Advanced BPCI Request for Applications
Q1 2018Participants selected
Spring 2018Agreements provided
Summer 2018Advanced BPCI data released
Critical that there is no break in BPCI participation
Potentially reduced application requirements for current BPCI participants
No rulemaking means participants enter into agreements w/CMS that include model specifications
Data will be imperative to deciding whether to participate
Historically, CMS uses 60 days a standard for data review prior to start (under downside risk)
Key questions for the future of bundled payments
• Which episodes continue on?• Eligible participants – beyond
hospitals?• Model expansion (ACA authority)?• Additional waivers?
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• More site neutralityo By allowing procedures (such as TKA) in the
outpatient settingo Allow prorated payments for IRF
• Outpatient-targeted bundles• Physician-focused models• Drug pricing models or adjustments to models
o Including more pharmacy drugs (Part D) o Additional waivers to allow price
negotiations• Overlaps with other models
Things to think about for future of CMS models…
What happens to BPCI Classic?
• Doubtful that CMS re-opens BPCI Classic• CMS could allow current participants a
bit more time to participate in current model due to some data issues throughout the model
Risks and opportunities in Advanced APMs
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$
$
$
$
$
$
Acute Care
HospitalLTCH
SNF
Rehab
HHA
Home Community Services
Opportunities+ Reduce unnecessary PAC utilization with patient-specific care plans+ Bring standardization to discharge process to reduce clinical variation+ Use data to form high quality PAC provider networks that provide efficient, high
quality care+ Reduce readmissions by guiding patients to the right place after discharge
Risks- Overutilization of post-acute care drives up episode costs without incremental
benefit to patients- Unmanaged patients readmit frequently, driving up CMS penalties and total
episode costs in alternative payment models- No tools and data to understand KPIs and drive operational changes
“Musts” for success in APMs
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Post-acute clinical decision support that is integrated into discharge planning workflow
Evidence-based intelligence to place patients in the most clinically appropriate PAC settings with the right resources to maximize functional recovery
Ability to identify and manage the highest risk patients early in the hospital stay
Alignment amongst health system leadership, hospital-based physicians, & case managers that value-based care is a priority
Connected and engaged networks of PAC providers that have been formed based on data-driven insights regarding quality outcomes, efficiency, and operational effectiveness
Allows for ability to monitor utilization and outcomes generated by PAC providers
Reporting and analytics to track performance, identify trends, and continuously drive operational improvements
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End-to-end solution personalizes the patient path across an episode
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Home
Community Services
Pre-Acute Acute Post-Acute Community/Home
Operating Room
!
Ouch!
EmergencyDepartment
Acute Care Hospital
LTCH
SNF
Rehab
HHA
Patient Risk and PAC Need StratificationPatient Specific PAC Care Planning
High Performing PAC NetworkCare Management & Evaluation
Patient Engagement & Monitoring
Patient Transition Patient Transition
Developing New APMs
Physician-Focused Payment Model Technical Advisory Committee
Financial Construct Is there any payment that you or your
constituents receive that is wasteful or unnecessary?How can you change the financial
constructs under which you operate to change behavior / incentives?
Clinical ConstructWhat aspects of robust clinical care
do you find yourself challenged to accomplish in your current environment? Are there any negative clinical impacts
of the way you currently practice?
How do you develop a robust proposal?
How many patients are affected?
Balancing the Possible Gains with Financial Liabilities
Financial Opportunities
APM payments (shared savings, reconciliation)5% lump sum incentive paymentSavings on quality reporting
Financial Liabilities
Cost of developing modelCost of implementing model (eg, care management staff, information technology)Possible APM losses Excess quality reporting cost
Case Study: Bundled Payment
Composition of a Bundled Payment
$8,000$6,000
$2,000$1,800
$1,200
$1,000
$6,000
$2,000
$1,000
$2,000
0
5,000
10,000
15,000
20,000
Status Quo Under Bundled Payment
Home HealthPost Acute CareAnesthesiologistSurgeonInpatient Stay
Total: $12,800
Total: $18,200
Example – Building a Commercial Arrangement
Am I Tracking to Meet My Target?
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What Cost Categories Are Driving Spending?
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Where Are Patients Going at Discharge?
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