CMS Innovation and Health Care Delivery System Reform Maine Chapter - PowerPoint PPT Presentation

CMS Innovation and Health Care Delivery System Reform Maine Chapter of the American Health Information Management Association March 17, 2 016 Andy Finnegan CMS RO1

Better. Smarter. Healthier. So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people .

CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people Evolving future state Historical state Public and Private sectors Key characteristics Key characteristics   Patient-centered Producer-centered  Incentives for outcomes  Incentives for volume   Sustainable Unsustainable   Coordinated care Fragmented Care Systems and Policies Systems and Policies  Value-based purchasing  Fee-For-Service Payment  Accountable Care Organizations Systems  Episode-based payments  Medical Homes  Quality/cost transparency 3

Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information “ Improving the way providers are incentivized, the { } way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system. FOCUS AREAS Pay Distribute Deliver Providers Information Care 4 Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

What is “MACRA” ? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 1 6, 2015. What does Title I of MACRA do? Repeals the Sustainable Growth Rate (SGR) Formula • Changes the way that Medicare rewards clinicians for value • over volume Streamlines multiple quality programs under the new Merit- • Based Incentive Payments System (MIPS) Provides bonus payments for participation in eligible • alternative payment models (APMs) 5

CMS has adopted a framework that categorizes payments to providers Category 1: Category 2: Category 3: Category 4: Fee for Service – Fee for Service – Alternative Payment Models Built Link to Quality on Fee-for-Service Architecture No Link to Value Population-Based Payment Description  Payments are  At least a portion  Some payment is linked to the  Payment is not directly based on of payments vary effective management of a triggered by service volume of based on the population or an episode of delivery so volume is not services and quality or care linked to payment  Payments still triggered by  Clinicians and not linked to efficiency of quality or health care delivery of services, but organizations are paid and efficiency delivery opportunities for shared responsible for the care of savings or 2-sided risk a beneficiary for a long period (e.g., ≥ 1 year)  Limited in  Hospital value-  Accountable Care Organizations  Eligible Pioneer Medicare  Medical homes Medicare fee- based purchasing Accountable Care Fee-for-  Physician Value  Bundled payments for-service Organizations in years 3-5 Service  Comprehensive Primary Care  Maryland hospitals  Majority of Modifier examples  Readmissions / initiative Medicare  Comprehensive ESRD Hospital Acquired payments now  Medicare-Medicaid Financial Condition are linked to Reduction Alignment Initiative Fee-For- quality Program Service Model 6 Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

During January 2015, HHS announced goals for value-based payments within the Medicare FFS system 7

Target percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models’ by 2016 and 2018 Alternative payment models (Categories 3-4) FFS linked to quality (Categories 2-4) All Medicare FFS (Categories 1-4) 2011 2014 2016 2018 0% ~20% 50% 30% ~70% >80% 85% 90% Historical Performance Goals 8

CMS will achieve Goal 1 through alternative payment models where providers are accountable for both cost and quality Major APM Categories 2014 2015 2016 2017 2018 Medicare Shared Savings Program ACO* Accountable Care Organizations Pioneer ACO* Comprehensive ESRD Care Model Next Generation ACO Bundled Payment for Care Improvement* Bundled Payments Specialty Care Models Advanced Comprehensive Primary Care* Primary Care Multi-payer Advanced Primary Care Practice* Maryland All-Payer Hospital Payments* Other Models ESRD Prospective Payment System* Model completion or expansion CMS will continue to test new models and will identify opportunities to expand existing models 9 * MSSP started in 2012, Pioneer started in 2012, BPCI started in 2013, CPC started in 2012, MAPCP started in 2011, Maryland All Payer started in 2014 ESRD PPS started in 2011

CMS is aligning with private sector and states to drive delivery system reform CMS Strategies for Aligning with Private Sector and states Convening Stakeholders Incentivizing Partnering Providers with States 10

The Health Care Payment Learning and Action Network will accelerate the transition to alternative payment models Network Objectives  Medicare alone cannot drive sustained progress towards alternative payment models (APM) • Match or exceed Medicare alternative payment model goals across the US health  Success depends upon a critical mass of partners system adopting new models -30% in APM by 2016 -50% in APM by 2018  The network will • Shift momentum from CMS  Convene payers, purchasers, consumers, states and to private payer/purchaser and state communities federal partners to establish a common pathway for success • Align on core aspects of  Identify areas of agreement around movement to APMs alternative payment design  Collaborate to generate evidence, shared approaches, and remove barriers  Develop common approaches to core issues such as beneficiary attribution  Create implementation guides for payers and purchasers 11

Accountable Care Organizations: Participation in Medicare ACOs growing rapidly  423 ACOs have been established in the MSSP and Pioneer ACO programs*  7.9 million assigned beneficiaries  This includes 89 new ACOS covering 1.6 million beneficiaries assigned to the shared saving program in 2015 ACO-Assigned Beneficiaries by County * April 2015 12

Medicare Shared Savings Program: Results to date Financial Results  In 2014:  92 ACOs (28%) held spending $806 million below their targets and earned performance payments of more than $341 million  In 2013 1 :  58 ACOs (26%) held spending $705 million below their targets and earned performance payments of more than $315 million Quality Results  ACOs that reported in both 2013 and 2014 improved average performance on 27 of 33 quality measures  Quality improvement was shown in such measures as patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctor , screening for tobacco use and cessation, and screening for high blood pressure 1 2013 figures include both 2012 and 2013 savings / loss generated for some ACOs that started mid-year in 2012 (these were the first ACOs in the program) 13

Pioneer ACOs meet requirement for expansion after two years and continued to generate savings in performance year 3  Pioneer ACOS were designed for organizations with experience in coordinated care and ACO-like contracts  Pioneer ACOs generated savings for three years in a row  Total savings of $92 million in PY1, $96 million in PY2, and $120 million in PY3 ‡  Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2 to $6.0 million in PY3 ‡  Pioneer ACOs showed improved quality outcomes  Mean quality score increased from 72% to 85% to 87% from 2012–2014  Average performance score improved in 28 of 33 (85%) quality measures in PY3  Elements of the Pioneer ACO have been incorporated into track 3 of MSSP  19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY , VT , WI) reaching over 600,000 Medicare fee-for-service beneficiaries  Duration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years ‡ Results from actuarial analysis 14

Independence at Home (IAH) Demonstration saves more than $3,000 per beneficiary  IAH tests a service delivery and shared savings model using home-based primary care to improve health outcomes and reduce expenditures for high- risk Medicare beneficiaries  In year 1, demo produced more than $25 million in savings , an average of $3,070 per participating beneficiary per year  CMS will award incentive payments of $11.7 million to nine practices that produced savings and met the designated quality measures for the first year  All 17 participating practices improved quality in at least three of the six quality measures  There are 17 total practices, including 1 consortium, participating in the model  Approximately 8,400 patients enrolled in the first year  Duration of initial model test: 2012 - 2015 15