CHASE Board April 2019 Nancy Dolson Department of Health Care Policy and Financing
Hospital Transformation Program Measure Scoring Summary Proposal 2
Background • CHASE and HCPF to seek CMS approval for a five-year delivery system reform incentive payment (DSRIP) program • State will leverage existing supplemental payments to hospitals as incentives in the statewide Hospital Transformation Program (HTP) • These hospital supplemental payments will be incentivized to: o Improve patient outcomes o Lower Medicaid costs o Prepare hospitals for value-based payment environments o Foster a culture of community engagement • In collaboration with hospitals and key stakeholders, HCPF has outlined how hospitals will be evaluated through key measures 3
Overview Five focus areas which the HTP seeks to address • Reducing avoidable inpatient and outpatient hospital utilization • Vulnerable populations • Behavioral health and substance-use disorder • Clinical and operational efficiencies • Population health and total cost of care 4
Five-Year Plan • Pre-program period sees participating hospitals conducting community and health neighborhood engagement (CHNE) process to inform their plans for the HTP • Throughout program years 1 to 5 HCPF will maintain transparency through public reporting on quality measures and hospital utilization • Reimbursement structure in program years 1 to 2 will be based on pay-for-reporting and pay-for-action • This will shift to pay-for-quality and pay-for-performance in program years 3 to 5, with percentage of hospital risk increasing annually • Value-based payment methods are envisioned post-HTP 5
Five-Year Plan • Hospitals will receive supplemental payments based on meeting program measures • For each measure and intervention, hospitals will develop improvement plans informed by CHNE with milestones for years 1-2 • As hospitals enact these plans, years 3-5 will build in measures of performance to improve care and health outcomes while reducing costs • Hospitals will also produce sustainability plans in year 5 • HCPF is recommending statewide measures, as well as local measures selected by individual hospitals based on their community’s needs 6
Downside Risk Pay-for-Reporting and Activity, Pay for Achievement, Performance and Improvement HCPF proposes that hospitals’ financial risk increase annually according to the following schedule Program Year Plan for Hospital Risk 1.5% for hospital applications PY1: 5% of payments at risk 1.5% for implementation plans 2% for timely reporting 2% for timely reporting PY2: 6% of payments at risk 4% for meeting proj ect milestones 2% for timely reporting 8% for meeting proj ect milestones 5% for meeting PY3: 15% of payments at risk measurement/ improvement thresholds *50% of penalties can be earned back by submitting course-correction plan 2% for timely reporting PY4: 20% of payments at risk 18% for meeting measurement/ improvement thresholds 2% for timely reporting 8% for submission and approval of PY5: 30% of payments at risk sustainability plan 20% for meeting measurement/ improvement thresholds 7
Upside Risk Redistribution of Penalty Dollars and Medicaid Savings Bonus • Redistribution of penalty dollars and savings bonuses • Savings bonuses refer to payments to hospitals based on costs savings in fee-for-service attributable to HTP efforts • For program years 2 to 3, the risk will comprise only of a redistribution of penalty dollars • For program years 4 to 5, HCPF recommends including savings bonuses • E.g., dollars could be redistributed to highest/most improved performers 8
Measure Development Process Measures evaluated based on key principles: Evidenced-based and scientifically acceptable • Usable and relevant • Feasible to collect • Aligned with other measure sets • Opportunity for quality improvement • Hospitals could impact • Representative of the array of services and diversity of • patients served 9
Measure Development Process Hospital measurement workgroups • Measurement specification workgroups • Clinical workgroup • 10
Statewide Measures At least one statewide measure is included in each of these five focus areas which the HTP seeks to address: • Reducing avoidable inpatient and outpatient hospital utilization • Vulnerable populations • Behavioral health and substance-use disorder • Clinical and operational efficiencies • Population health and total cost of care 11
Statewide Measures: Examples Clinical and Reducing Avoidable Behavioral Health and Population Health and Vulnerable Populations Operational Hospital Utilization Substance Use Disorders Total Cost of Care Efficiencies • • • • • 30-day all cause risk RAE follow-up after S ocial Determinant s of Hospital Risk Adj usted Length adj usted readmission discharge from IP or ED Health S creening and Index of S tay (adult CMS rate (adult CMS with MH covered diagnosis Referral To the RAE specification - • Health Waste specification - pediatric • RAE follow-up after Calculator pediatric spec AHRQ) specification to be discharge from IP or ED determined ) with S UD covered diagnosis • Using ALTOs in ED • Opioid prescriptions in ED • Opioid prescribing guidelines for post- surgical and chronic pain in out years 12
Local Measures • Hospitals will select from an array of local measures to comprise the remainder of their measurement score • There is a local measures menu within each of the five focus areas • It is recommended that there be no required number of local measures per focus area but rather the mix of local measure selections should reflect community needs identified in CHNE 13
Local Measures: Examples Clinical and Reducing Avoidable Hospital Behavioral Health and Vulnerable Populations Operational Utilization Substance Use Disorders Efficiencies • • • • Connection to PCP prior to Initiation of S UD Utilization of MAT for Opportunity Days – discharge and follow-up treatment within 14 days perinatal/ postpart um women APR-DRG actual appointment made of new diagnosis of S UD presenting S UD vs. expected days (AHRQ) • • • ED visits for which the 7-day readmission rate for a high Increased • member received follow-up S creening for depression frequency chronic condition utilization of within 30 days of the ED and suicide risk in IP and telehealth • Implementation/ expansion of visit (HEDIS ) ED • telehealth visits Energy S tar • • Home Management Plan of S BIRT in the Emergency Certification • S creening for transitions of care Care (HMPC) Document Room supports in adults with disabilities Given to Pediatric Asthma • Use of Prescription Drug Patient/ Caregiver (eCQM) Monitoring Program prior • Percentage of patients with to opioid prescription for ischemic stroke who are ED patients discharged on statin • Initiation of MAT in medication (eCQM) Emergency Room • 3 Item Care Transitions Patient S urvey Measure (CMS ) 14
State Priorities • Statewide priority opportunities listed below be weighted more heavily to incentivize hospitals to undertake these efforts • Conversion of hospital-owned free-standing emergency departments (FSED) to address community needs • Dual-track emergency departments • Participation in a global budget or other arrangement for certain rural hospitals, if available 15
Complementary Statewide Efforts • Discussion of hospital inventory and capacity as part of the CHNE • Engagement with a multi-provider consensus quality measure and alternative payment methodology (APM) collaborative • Use of the Advanced Care Plan Repository and Education Tools • Use of the Medication (Rx) Prescribing Tool • Where capacity/need align, provide beds for residential and inpatient SUD services consistent with SUD Waiver • Real time Data Sharing and ADT Standards • Defining and identifying Centers of Excellence 16
Discussion 17
Hospital Quality Incentive Payment Proposed Changes for Board Decision 18
HQIP • Behavioral Health Measures • Follow-up appointments within 7 days after hospital discharge • Emergency department utilization for mental health and substance use conditions • Subcommittee recommendation • Revert to the 2018 RCCO/BHO measures 19
HQIP • Hospital Index Measure • Development timeline for Hospital Index • Subcommittee recommendation • Revise the requirements of the Hospital Index measure to a process measure demonstrating ability to use the tool and extract basic information 20
Board Decision 21
Thank You Nancy Dolson Special Financing Division Director Department of Health Care Policy & Financing nancy.dolson@state.co.us
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