Fundamentals of Healthcare Reform

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Transcript Fundamentals of Healthcare Reform

Fundamentals of Healthcare Reform

Walter Coleman WV/PA HFMA September 25, 2014

How about efficiency?

Waste in the System

Industry Tipping Point

Time • How do

local market conditions impact

timing considerations?

• Can

market-changing events

create an urgent paradigm shift?

• What is my

step-change business model

risk?

• Do I have the

financial tools

to adequately analyze relevant states?

6

Healthcare Performance Program Umbrella

Mandatory Element of Reform

VALUE BASED PURCHASING

Value Based Purchasing Overview

• MANDATORY – we have no choice

VBP Example

$33,333,333 Medicare Reimbursement Amount mandated to pay for participation

VBP Example

$33,333,333 Medicare Reimbursement

VBP Example

$33,333,333 Medicare Reimbursement

VBP Example

$33,333,333 Medicare Reimbursement Amount mandated to pay for participation

VBP Example

$33,333,333 Medicare Reimbursement

VBP Example

$33,333,333 Medicare Reimbursement

Value Based Purchasing

• Outcomes = Income • Mandatory Pay for Performance Program – 3,500 hospitals are included in this program across the country • Reimbursement Determine Two Ways: – Achievement • How we compare to National Top Decile (350 Hospitals) – Improvement • How we measure against ourselves • Did we do better than a previously measured baseline period

Value Based Purchasing

• Percent of Medicare Reimbursement at Risk • FY 2013 – 1.00% • FY 2014 – 1.25% • FY 2015 – 1.50% • FY 2016 – 1.75% • FY 2017 – 2.00% • FY 2018 – 2.00% • FY 2019 – 2.00% • FY 20xx – refers to the Federal Fiscal Year (Oct. 1 – Sep. 30) when DRG payments will be affected

Value Based Purchasing

NEW MEASURES

VBP FY 2016 – New Measures

• Patient Experience – No Change – Same HCAHPS Measures • Core Measures – 5 Dropped; 1 New • Outcomes – 3 New Measures • Efficiency – No Change

VBP FY 2016 – New Measures

• Patient Experience – No Change – Same HCAHPS Measures • Core Measures – 5 Dropped; 1 New • Outcomes – 3 New Measures • Efficiency – No Change

VBP – FY 2016 – Patient Experience

• HCAHPS – Hospital Consumer Assessment of Healthcare Providers Survey – An engagement survey CMS has mandated each hospital give to every discharged inpatient – Consists of 27 questions that lead to the 8 categories assessed for VBP – Patients score each question on scale of 4 – For answers to

count

, patients must give hospitals a score of 4 or “Always”

VBP FY 2016 – Patient Experience

• Communication with Nurses • Communication with Doctors • Responsiveness of Hospital Staff • Pain Management • Communication about Medicines • Cleanliness and Quietness of Hospital • Discharge Information • Overall Rating of Hospital

VBP FY 2016 – New Measures

• Patient Experience – No Change – Same HCAHPS Measures • Core Measures – 5 Dropped; 1 New • Outcomes – 3 New Measures • Efficiency – No Change

VBP FY 2015 – Core Measures

• AMI-7a • AMI-8a • HF-1 • PN-3b • PN-6 • SCIP-Inf-1 • SCIP-Inf-2 • SCIP-Inf-3 • SCIP-Inf-4 • SCIP-Inf-9 • SCIP-Card-2 • SCIP-VTE-2

VBP FY 2016 – Core Measures

• AMI-7a • SCIP-Inf-9 • PN-6 • SCIP-Inf-2 • SCIP-Inf-3 • • SCIP-Card-2 • SCIP-VTE-2

IMM-2

Note:

IMM-2 Performance Period is only 6 MONTHS (Two 3 Month Periods)

January 1, 2014 – March 31, 2014 AND October 1, 2014 – December 31, 2014

VBP FY 2016 – Core Measures

Measure ID

AMI-7a IMM-2 PN-6 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-9 SCIP-Card-2 SCIP-VTE-2

Benchmark

100% 98.875% 100% 100% 100% 100% 100% 100%

VBP FY 2016 – Core Measures

• AMI-7a • SCIP-Inf-9 • PN-6 • SCIP-Inf-2 • SCIP-Inf-3 • SCIP-Card-2 • SCIP-VTE-2 • IMM-2

VBP FY 2017 – Clinical Care: Process

• AMI-7a • IMM-2 •

PC-01

PC-01 = Elective Delivery Prior to 39 Completed Weeks Gestation

VBP FY 2016 – New Measures

• Patient Experience – No Change – Same HCAHPS Measures • Core Measures – 5 Dropped; 1 New • Outcomes – 3 New Measures • Efficiency – No Change

VBP FY 2015 – Outcomes

• 30 Day Mortality – AMI • 30 Day Mortality – HF • 30 Day Mortality – PN • AHRQ – PSI-90 • CLABSI

VBP FY 2016 – Outcomes

• 30 Day Mortality – AMI • 30 Day Mortality – HF • 30 Day Mortality – PN • AHRQ – PSI-90 • CLABSI •

CAUTI

SSI – Colon

SSI – Abdominal Hysterectomy

VBP FY 2016 – Outcomes

Measure ID

CAUTI CLABSI Surgical Site Infection Colon Abdominal Hysterectomy

Benchmark

0.000

0.000

0.000

0.000

VBP FY 2016 – Outcomes

Outcomes • 30 Day Mortality – AMI • 30 Day Mortality – HF • 30 Day Mortality – PN • AHRQ – PSI-90 • CLABSI • CAUTI • SSI-Colon • SSI-Abdominal Hyster.

VBP FY 2017 – Clinical Care and Safety

Clinical Care- Outcomes • 30 Day Mortality – AMI • 30 Day Mortality – HF • 30 Day Mortality – PN • AHRQ – PSI-90 • CLABSI • CAUTI • SSI-Colon • SSI-Abdominal Hyster.

Safety • •

MRSA C. Diff

Outcomes – 30 Day Mortality

• Currently in

3

Performance Periods • FY 2016

ended

June 30, 2014 • FY 2019

began

July 1, 2014 • 30 Day Mortality Measures – Assess deaths: AMI, HF, and PN that occur within 30 days after

admission

; which, depending on the length of stay, may occur post discharge….

CMS 30 Day Risk-Standardized Mortality Rate Calculation

Facility

Predicted

Deaths

= X

Measure (AMI, HF, PN) National Crude Rate Facility

Expected

Deaths

VBP FY 2016 – New Measures

• Patient Experience – No Change – Same HCAHPS Measures • Core Measures – 5 Dropped; 1 New • Outcomes – 3 New Measures • Efficiency – No Change

VBP FY 2016 - Efficiency

• Medicare Spend Per Beneficiary (MSPB) – Captures total Medicare Spending Per Beneficiary relative to a hospital stay, bundling hospital sources (Part A) with post acute care (Part B) – Bundles the cost of care delivered to a beneficiary for an episode across the continuum of care: • 3 Days Prior • Hospital Inpatient Stay • 30 Days post Discharge

PROPOSED MSPB Measures

• Additional Efficiency Measures proposed to be added

Medical Surgical

Kidney/Urinary Tract Infection Cellulitis Hip replacement/revision Knee replacement/revision Gastrointestinal Lumbar spine • Proposed to facilitate alignment with the Physician Value Based Payment Modifier program • Includes Part A and B and 3 days prior to admission and 30 days post discharge 41 SOURCE: May 1, 2014 Federal Register

VBP Shifting of Domain Weights

FY 2013 FY 2014 FY 2015 FY 2016

• •

Core Measures Patient Experience

• •

Outcomes Efficiency (MSPB)

VBP – FY13 Domain Weights

Performance Period: July 1, 2011 – March 31, 2012 Reimbursement Period: October 1, 2012 – September 30, 2013 Core Measures = 70%

VBP – FY14 Domain Weights

Performance Period: April 1, 2012 – December 31, 2012 Reimbursement Period: October 1, 2013 – September 30, 2014 Outcomes = 25% Core Measures = 45%

VBP – FY15 Domain Weights

Performance Period: January 1, 2013 – December 31, 2013 Reimbursement Period: October 1, 2014 – September 30, 2015 HCAHPS = 30% Core Measures = 20% Outcomes = 30% MSPB = 20% One Measure!!

VBP – FY16 Domain Weights

Performance Period: January 1, 2014 – December 31, 2014 Reimbursement Period: October 1, 2015 – September 30, 2016 Core Measures = 10% HCAHPS = 25% MSPB = 25% Outcomes = 40%

VBP – FY17 Domain Weights

Performance Period: January 1, 2015 – December 31, 2015 Reimbursement Period: October 1, 2016 – September 30, 2017 Clinical Care - Process = 5% HCAHPS = 25% Clinical Care Outcomes = 25% Safety = 20% MSPB = 25%

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Crosswalk from FY 16 to FY 17

Measure

Core Measures HCAHPS

Prior Domain (FY’16)

Clinical Process of Care Patient Experience of Care CAUTI/CLABSI/SSI Mortality – 3 diagnoses PSI- 90 Medicare Spend Per Beneficiary Outcomes Outcomes Outcomes Efficiency

NQS Domain (FY’17)

Clinical Care- Process Patient & Caregiver Centered Experience of Care/Care Coordination Safety Clinical Care- Outcomes Safety Efficiency & Cost Reduction

Fundamentals of Healthcare Reform

ANALYZING VALUE BASED PURCHASING PERFORMANCE

$288,853 $4,925,357

Breakeven Point: $5,301,360 Breakeven Point: $451,333

$0 $0

• System was penalized

$376,003

in FY’15 VBP Program • Must acknowledge the amount

UNEARNED

• Of the programs dollars made available: – System did not capitalize on

$6,187,541

Facility Facility A Bonus / (Penalty) $97,593 Total Score 42.03

Core Measures

AMI-8a SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-4 SCIP-Inf-9 HF-1 PN-3b PN-6 SCIP-Card-2 SCIP-VTE-2

Core Measures TOTAL HCAHPS

Comm. w/ Nurses Comm. w/ Doctors Resp. of Hosp. Staff Pain Management Comm. Re: Medicines Clealiness & Quietness Discharge Information Overall Rating Consistency Score

HCAHPS TOTAL Outcomes

AMI HF PN AHRQ PSI-90 CLABSI

Outcomes TOTAL Efficiency

MSPB

Efficiency TOTAL Facility TOTAL Measure Score

5 8 3 5 6 9 7 5 9 5 8 2 1 2 2 1 2 3 1 17 10 3 8 9 0 1

State Average 41.81933117

Amount Earned by Measure

$ 32,712 $ 49,068 $ 38,164 $ 27,260 $ 49,068 $ 27,260 $ 43,616 $ 27,260 $ 43,616 $ 16,356 $ 27,260

$ 381,643 National Average 41.70169535

Amount Unearned by Measure

$ 21,808 $ 5,452 $ 16,356 $ 27,260 $ 5,452 $ 27,260 $ 10,904 $ 27,260 $ 10,904 $ 38,164 $ 27,260

$ 218,077

$ 17,994 $ 8,998 $ 17,994 $ 17,994 $ 8,998 $ 17,994 $ 26,990 $ 8,998 $ 152,933

$ 278,896

$ 71,966 $ 80,962 $ 71,966 $ 71,966 $ 80,962 $ 71,966 $ 62,970 $ 80,962 $ 26,987

$ 620,704

$ 179,920 $ 53,980 $ 143,934 $ 161,928 $ 0

$ 539,763

$ (0) $ 125,940 $ 35,986 $ 17,992 $ 179,920

$ 359,837

$ 59,974

$ 59,974 $ 1,260,277

$ 539,746

$ 539,746 $ 1,738,363 National Δ 0.325577377

% of Measure Earned

60.00% 90.00% 70.00% 50.00% 90.00% 50.00% 80.00% 50.00% 80.00% 30.00% 50.00%

63.64%

20.00% 10.00% 20.00% 20.00% 10.00% 20.00% 30.00% 10.00% 85.00%

31.00%

100.00% 30.00% 80.00% 90.00% 0.00%

60.00% 10.00% 42.03%

Facility Earned Back $381,643

Breakeven Point: $232,525

Core Measures Unearned $218,077 Measure Value $599,720 $381,643 % Earned 63.64% Facility Earned Back $539,763

Breakeven Point: $348,788

Outcomes Unearned $359,837 Measure Value $899,600 % Earned 60.00% $539,763 $0 $599,720 $0 $899,600 Facility Earned Back $278,896 $278,896 HCAHPS Unearned $620,704 Measure Value $899,600

Breakeven Point: $348,788

% Earned 31.00% Facility Earned Back $59,974 Efficiency Unearned Measure Value $539,746 $599,720

Breakeven Point: $232,535

% Earned 10.00% $0 $899,600 $59,974 $0 $599,720

Mandatory Element of Reform

READMISSION REDUCTION PROGRAM

Readmission Reduction Program

• 9% of Current and Future Medicare Reimbursement at Risk – 3% penalty of Medicare Reimbursement at risk each program year – Measured Populations 30 days from

DISCHARGE

• AMI, HF, PN, COPD, THA & TKA • August 2014: CABG Added to FY 2017 • Performance Periods: 3 Year Rolling Program – – – – –

FY’15

: July 1, 2010 – June 30, 2013 – 3%

FY’16

: July 1, 2011 – June 30, 2014 – 3%

FY’17

: July 1, 2012 – June 30, 2015 – 3%

FY’18

: July 1, 2013 – June 30, 2016 – 3%

FY’19

: July 1, 2014 – June 30, 2017 – 3% Currently participating in

3

performance periods simultaneously

How are Readmissions Measured?

• Scoring Index based at 1.0

• Calculate Excess Readmission Ratio

Facility

Predicted

Value Facility

Expected

Value

• Excess Readmission Ratio > 1 =

BAD

• Excess Readmission Ratio < 1 = GOOD

Mandatory Element of Reform

HOSPITAL ACQUIRED CONDITIONS

Hospital Acquired Conditions

(1% at Risk*)

• 12 Hospital Acquired Conditions Identified – Divided in to 2 Domains • If a hospital is in the

BOTTOM QUARTILE

(worst performing 25% in the country), it will be penalized a

FULL 1%

of Medicare Reimbursement • Penalties will begin FY’15 (beginning October 1, 2014) *1% After DSH, Uncompensated Care, and IME

Hospital Acquired Conditions: FY 2015

First Domain: PSIs Performance Period: 7/1/11-6/30/13

Pressure Ulcer Rate Iatrogenic Pneumothorax Rate Central Venous Catheter-Related Bloodstream Infections Postoperative Hip Fracture Postoperative Pulmonary Embolism and Deep Vein Thrombosis Rate Postoperative Sepsis Postoperative Wound Dehiscence

Second Domain: CDC Performance Period: CY 2012 & 2013

CLABSI CAUTI

HAC Domain Weightings: FY’15 DOMAIN 1: 35%

DOMAIN 2: 65% Postop. Sepsis 5,0% CLABSI 32,5% Pressure Ulcer 5,0% CAUTI 32,5%

Hospital Acquired Conditions: FY 2016

First Domain: PSIs 25%

Pressure Ulcer Rate Iatrogenic Pneumothorax Rate Central Venous Catheter-Related Bloodstream Infections Postoperative Hip Fracture Postoperative Pulmonary Embolism and Deep Vein Thrombosis Rate Postoperative Sepsis Postoperative Wound Dehiscence

Second Domain: CDC 75%

CLABSI CAUTI SSI Following Colon Surgery (FY 2016) SSI Following Abdominal Hysterectomy (FY 2016)

HAC Domain Weightings: FY’15 DOMAIN 1: 25%

DOMAIN 2: 75% Postop. Sepsis 3,6% CLABSI 25,0% Pressure Ulcer 3,6% SSI 25,0% CAUTI 25,0%

Hospital Acquired Conditions: FY 2017

First Domain: PSIs 25%

Pressure Ulcer Rate Iatrogenic Pneumothorax Rate Central Venous Catheter-Related Bloodstream Infections Postoperative Hip Fracture Postoperative Pulmonary Embolism and Deep Vein Thrombosis Rate Postoperative Sepsis Postoperative Wound Dehiscence

Second Domain: CDC 75%

CLABSI CAUTI SSI Following Colon Surgery (FY 2016) SSI Following Abdominal Hysterectomy (FY 2016) Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia (FY 2017) Clostridium Difficile (FY 2017)

Duplicate Measures

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Penalties & Your DRG Payment

SAMPL IPPS Reimbursement Letter PPS EFFECTIVE 10/1/2014

DRG Weight Facility CMI OPERATING INFORMATION

Federal National Standardized Labor Rate Wage Index Labor Rate x Wage Index Federal National Standardized Non-Labor Rate PPS Blended Rate

FY 2015 Hospital Readmissions Reduction (HRR) Adjustment Factor FY 2015 Value-Based Purchasing (VBP) Adjustment Factor

0.9994

0.994348

1.00

1.54

3,329.57

0.8994

2,994.62

2,040.71

5,035.33

5,032.30

5,003.86

($3.02)

RRP Reduction

($28.44)

VBP Reduction

($31.46)

Per DRG Reduction ($31.46) x 1.54

Disproportionate Share Adjustment (Operating) (Empirically Justified Amount 25%) Disproportionate Share Adjustment (Operating) (Uncompensated Care Amount) Fully Loaded Operating Rate adjusted for CMI

FY 2015 Hospital Acquired Condition (HAC) Adjustment Factor

0.0691

0.99

($48.45)

VBP & RRP Per DRG Red. CMI Adj 0.02

507.71

5,090.43

5,598.14

8,346.97

8,263.50

($83.47)

HAC Per DRG CMI Adjusted

($131.92) Total Per DRG Reduction

Mandatory Elements of Reform

CURRENT DOLLARS AT RISK SAMPLE $50,000,000 FACILITY

VBP FY 2016 – Sample Current $$ at Risk

Domain

Medicare Spend Per Beneficiary Outcomes Patient Experience Core Measures

VBP FY 2016 Weight

25% 40% 25% 10%

At Risk

$ 745,471 $ 1,192,753 $ 745,471 $ 298,188

On the Table

$ 1,562,507 $ 2,500,011 $ 1,562,507 $ 625,003

TOTAL 100% $ 2,981,883 $ 6,250,028

VBP – Sample Total Current $$ at Risk

VBP Current Dollars At Risk (Active Performance Periods) Domain Weight At Risk On the Table FY 2016

Medicare Spend Per Beneficiary Outcomes Patient Experience Core Measures 25% 40% 25% 10% $ $ 1,192,753 $ $ 745,471 745,471 298,188 $ $ $ 1,562,507 2,500,011 1,562,507 $ 625,003

FY 2017

Outcomes - 30 Day Mortality Outcomes - AHRQ

FY 2018**

Outcomes - 30 Day Mortality Outcomes - AHRQ

FY 2019**

Outcomes - 30 Day Mortality 25% 3.75% 25% 3.75% 25% $ $ $ $ $ 851,967 127,795 851,967 127,795 851,967 $ $ $ 1,785,722 1,785,722 $ $ 267,858 267,858 1,785,722

TOTAL $ 5,793,374 $ 12,142,911

All Reform – Sample Total Current $$ at Risk

All Active Mandatory Reform Domain On the Table FY 2016

Value Based Purchasing Readmissions Hospital Acquired Conditions

FY 2017

$

COMPLETE

$ 6,250,028 1,703,933 Value Based Purchasing Readmissions Hospital Acquired Conditions

FY 2018**

Value Based Purchasing Readmissions

FY 2019**

Value Based Purchasing** Readmissions $ 2,053,581 $ 5,111,800 $ 1,703,933 $ $ $ $ 2,053,581 5,111,800 1,785,722 5,111,800

TOTAL $ 30,886,178

Mandatory Elements of Reform

OPPORTUNITIES

New NQS Based Domains for FY 2017

Clinical Care Process = 5% HCAHPS = 25% Clinical Care Outcomes = 25% Safety = 20% MSPB = 25%

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50% of VBP is Mortality and MSPB

Clinical Care Outcomes = 25%

72

Opportunities – VBP: Outcomes

1 30 Day Mortality Rate - PN

Performance Baseline Threshold Benchmark Score FY14 87.40% 89.58% 88.18% 90.21% 0 ∆ -2.18% -0.78% -2.81%

Improvement +1% +1.5% +2.5% +3.5% +4.5% +5.5% +6.5% +7.5% +8.5% Dollar Value $ 13,209 $ 52,836 $ 105,673 $ 132,091 $ 132,091 $ 132,091 $ 132,091 $ $ 132,091 132,091 Score 1 4 8 10 10 10 10 10 10 2 30 Day Mortality Rate - AMI

Performance Baseline Threshold Benchmark Score FY14 83.81% 84.76% 84.77% 86.73% 0 ∆ -0.95% -0.96% -2.92%

Improvement +1% +1.5% +2.5% +3.5% +4.5% +5.5% +6.5% +7.5% +8.5% Dollar Value $ 13,209 $ 39,627 $ 105,673 $ 132,091 $ 132,091 $ 132,091 $ 132,091 $ $ 132,091 132,091 Score 1 3 8 10 10 10 10 10 10 3 30 Day Mortality Rate - HF

Performance Baseline Threshold Benchmark Score FY14 85.21% 88.94% 88.61% 90.42% 0 ∆ -3.73% -3.40% -5.21%

Improvement +1% +1.5% +2.5% +3.5% +4.5% +5.5% +6.5% +7.5% +8.5% Dollar Value $ $ $ $ 13,209 $ 79,254 $ 132,091 $ 132,091 $ $ 132,091 132,091 Score 0 0 0 1 6 10 10 10 10 Top 50 th = Δ1 Patient Top 10 th = Δ3 Patient Top 50 th = Δ1 Patient Top 50 th = Δ8 Patients Top 10 th = Δ3 Patient Top 10 th = Δ11 Patients

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VBP – CMS Proposed Future Measures

• FY 2018 Program (Performance Period: CY 2016) – Patient Experience:

Care Transition

• FY 2019 Program (Performance Period: CY 2017) – Surgical Complication:

Total Hip and Total Knee Arthroplasty

VBP – Other Possible Metrics to Follow

• Emergency Department Care • Preventative Care – Pneumonia Vaccine • Children’s Asthma Care • Stroke Care – Blood Clot Prevention Care – Preventative Care

FY 19 New Measure

• Added THA/TKA for 30 month performance period. – January 1, 2015-June 30, 2017 – Baseline of July 1, 2010-June 30, 2013 • Risk standardized measure for complications after Total Hips and Knees surgeries for up to 90 days post surgery – One of eight complications: AMI, pneumonia, sepsis, SSI, PE, death, mechanical complication or periprosthetic joint infection/wound infection.

– Each has a defined time frame – Each is a ‘Yes’ or ‘No – Risk adjusted for patient age, sex and comorbidities SOURCE: August 2014 Proposed Rules Federal Register 76

Readmissions – Proposed Future Measures

• Percutaneous Coronary Intervention (PCI) • Stroke

Opportunities – HAC

• SSI Following Colon Surgery (FY’16) • SSI Following Abdominal Hysterectomy (FY’16) • MRSA (FY’17) • C Diff (FY’17)

BPCI BUNDLED PAYMENTS

Description of Models 1 - 4

80

Bundled Payments

Post Acute Care Bundling Acute Care Episode with Post Acute Care Bundling Acute Care Bundling Medical Homes

©2010 Kaufman Hall & American Hospital Association.

81

Advantages of Participation

• Improved quality of care for patients – Reduced complications, readmissions, and cost • Improved ability to work with hospitals, physicians, nursing homes, home health, rehab centers, and other providers to improve overall care quality and service • Potential competitive advantage within market with physicians and post-acute care • Opportunity to receive payment aligned with these goals and based on outcomes 82

Where are the Bundled Payments?

MEDICARE: Cohort 1 COMMERCIAL as of July 2014

http://innovation.cms.gov/initiatives/bundled-payments/ 83

Early Results of BPCI Cohort 2

• Tremendous increase in the number of applications in the most recent open enrollment in April 2014: Nearly Triple!

• Models 2,3,4 were open for enrollment • Currently in the Phase 1 period which is the non risk, decision making period. Phase 2 is when the Episode Initiator starts to accept risk

Changes In the Cohort 2 Timeline: 7/31/14

Event

Historical Claims & Target Pricing Go/No Go Decision to Participate Go Live with Risk

Original Date

Late Summer 2014 November 1, 2014 January 1, 2015

Revised Date

October 2014 January 1, 2015 April 1, 2015 Other significant changes: 

ADDITION OF EPISODES

: You can now add episodes in July 2015 and October 2015: only 1 episode is required for April 1,   2015. Phase 1 ends in October 2015

B-CARE

: B-CARE quality data wont be collected until Spring 2015

Option for Delayed Reconciliation

: Will offer a 4 quarter timeline for reconciliation.

DRG 470 Total Joint Replacement w/out CC Model 2

$3,207 +

DRG Inpatient and PACS Fee for Service Model

$10,129 + $8,965 + $616 = MD • Home Health • SNF • IRF • Outpt. Rehab

Home

Readmission $22,927 x 98% $22,468 Episodic period for model 2: 3 days prior to admission to 90 days post discharge from hospital $22,468

Bundled Episodic Model

Note:

any CMI aggregate charges lower than $22,468 can be shared with providers via gain sharing model

BPCI Multiple Bonus Payments: Physicians

2

opportunities for Physicians to be awarded Bonuses 1.

Internal Cost Savings Pool 2.

Bundled Payment Savings Pool • Both have required Quality Metrics and Cost Savings to be met • Cost Savings

MUST

be directly attributed to Quality Improvement and Care Redesign 87

BPCI Multiple Bonus Payments: Physicians

2

opportunities for Physicians to be awarded Bonuses 1.

Internal Cost Savings Pool 2.

Bundled Payment Savings Pool • Both have required Quality Metrics and Cost Savings to be met • Cost Savings

MUST

be directly attributed to Quality Improvement and Care Redesign 88

Internal Cost Savings

• DHG Healthcare has one of very few, if not the only, Internal Cost Savings Gainshare models to have been submitted and approved by CMS at this time

APPROVED

Outpatient Bundling…coming soon?

In February 2014, CMMI issued a Request for Information on a new bundled payment program to expand to outpatient.

Focus is Specialty Physicians and on (1) Procedures and (2) complex chronic care

• Highlighted colonoscopy, cataract surgery, & radiation therapy for procedural options. • Regarding the chronic care, “

CMS is considering development of a model that would incentivize specialists to more efficiently manage the care provided to beneficiaries with complex or chronic medical conditions over the period of time that corresponds to the specialty practitioner’s long term involvement with managing the beneficiary’s care.”

• Was seeking responses until March 13

Outpatient Bundling

• Referred to by CMS as:

“Comprehensive Ambulatory Payment Classification (APC)”

• Finalized in the CY 2014 OPPS/ASC Final Rule • Affect payments to 4,000 hospitals and 5,300 ASC’s • Delayed implementation to

January 1, 2015

instead of the traditional outpatient October 1 implementation date – Extra time allowed the Agency, hospitals, and physicians more time to evaluate and comment on the policy

Outpatient Bundling – Comprehensive APC’s

• Single Medicare payment rather than individual APC payments throughout the episode • 28 Bundled Outpatient Procedures • Proposed Payment could include all hospital services reported on the claim covered under Medicare Part B for up to a proposed 6 Month Period – Few exceptions resulting in a single beneficiary copayment per claim

Outpatient Bundling – Proposed Procedures

No.

Clinical Family

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 24 25 26 27 28 16 17 18 19 20 21 22 23 AICDP AICDP AICDP AICDP AICDP BREAS CATHX CATHX ENTXX EPHYS EPHYS EPHYS EYEXX EYEXX GIXXX NSTIM NSTIM NSTIM ORTHO PUMPS RADTX UROGN UROGN UROGN VASCX VASCX VASCX VASCX

Proposed CY 2015 APC

0090 0089 0655 0107 0108 0648 0427 0652 0259 0084 0085 0086 0293 0351 0384 0061 0039 0318 0425 0227 0067 0202 0385 0386 0083 0229 0319 0622

APC Title

Level II Pacemaker and Similar Procedures Level III Pacemaker and Similar Procedures Level IV Pacemaker and Similar Procedures Level I ICD and Similar Procedures Level II ICD and Similar Procedures Level IV Breast and Skin Surgery Level II Tube or Catheter Changes or Repositioning Insertion of Intraperitoneal and Pleural Catheters Level VII ENT Procedures Level I Eletrophysiologic Procedures Level II Eletrophysiologic Procedures Level III Eletrophysiologic Procedures Level IV Intraocular Procedures Level V Intraocular Procedures GI Procedures with Stents Level II Neurostimulator & Related Procedures Level III Neurostimulator & Related Procedures Level IV Neurostimulator & Related Procedures Level V Musculoskeletal Procedures Except Hand and Foot Implantation of Drug Infusion Device Single Session Cranial Stereotactic Radiosurgery Level V Female Reproductive Procedures Level I Urogenital Procedures Level II Urogenital Procedures Level I Endovascular Procedures Level II Endovascular Procedures Level III Endovascular Procedures Level II Vascular Access Procedures

Proposed CY 2015 APC Geometric Mean Cost

$ 6,961.45 $ 9,923.94 $ 17,313.08 $ 24,167.80 $ 32,085.90 $ 7,674.20 $ 1,522.15 $ 2,764.85 $ 31,273.34 $ 922.84 $ 4,807.69 $ 14,835.04 $ 9,049.66 $ 21,056.40 $ 3,307.90 $ 5,582.10 $ 17,697.46 $ 27,283.10 $ 10,846.49 $ 16,419.95 $ 10,227.12 $ 4,571.06 $ 8,019.38 $ 14,549.04 $ 4,537.95 $ 9,997.53 $ 15,452.77 $ 2,635.35

Outpatient Bundling – Summary

• Comprehensive APC is another step towards CMS establishing a Prospective Payment Model for OPPS • Goal: eliminate avoidable costs and increase shared decision making • Healthcare stakeholders who have been on the sidelines for recent CMS pilots and existing programs will not have this luxury as CMS expands their delivery and payment reform portfolio in the upcoming calendar year

Thank you!

Contact Information: Walter Coleman [email protected]

(804) 474-1248