FORHP Policy Updates – November 8, 2017 • CY 2018 Quality Payment Program Final Rule (Effective 01/01/18) • Increases in the low volume threshold to ≤ $90,000 or ≤200 beneficiaries (Part B) • Method II CAHs are required to participate if above the low volume threshold • CY 2018 Outpatient PPS Final Rule (Effective 01/01/18) • Reinstates the non-enforcement of direct supervision requirement for outpatient therapeutic services in CAHs for CY 2018 and CY 2019 • Reduces reimbursement for 340B-purchased drugs from ASP+6% to ASP -22.5% with exception for rural sole community hospitals. • Note: CAHs will continue to receive cost-based reimbursement for their 340B-purchased drugs since they are not paid under OPPS. • CY 2018 Physician Fee Schedule Final Rule (Effective 01/01/18) • Creates a general care management bundled code for RHCs/FQHCs • Policy updates for Medicare Diabetes Prevention Program 1
FORHP Policy Updates continued • CMS Innovation Center Request for Information (RFI) – New Direction • In particular, the Innovation Center is interested in testing models in the following eight focus areas: 1.Increased participation in Advanced Alternative Payment Models (APMs); 2.Consumer-Directed Care & Market-Based Innovation Models; 3.Physician Specialty Models; 4.Prescription Drug Models; 5.Medicare Advantage (MA) Innovation Models; 6.State-Based and Local Innovation, including Medicaid-focused Models; 7.Mental and Behavioral Health Models; and 8.Program Integrity. • Comment by November 20, 2017 • More information available at: https://innovation.cms.gov/initiatives/direction/ 2
Flex Grant Timeline Projection only, subject to change Updated 11-3-2017 Major reporting for 2017 - 2022 2016 2017 2018 2019 S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A Project Year 2 (FY 16) Project Year 3 (FY 17) Project Year 4 (FY18) NCC Progress Reports Y2 Y3 PIMS Reports Y1 Y2 Y3 Competing Applications New Financial Reports FFR FY15 FFR FY16 FFR FY17 2020 2021 2022 2019 S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D New Project Year 1 (FY19) New Project Year 2 (FY20) New Project Year 3 (FY21) Year 4 NCC Progress Reports Y1 Y2 Y3 PIMS Reports Y4 Y1 Y2 Y3 Competing Applications Financial Reports FFR FY18 FFR FY19 FFR FY20 FFR FY21
Center for Rural Health Policy Analysis Rural Health Value Tools and Resources TASC 90 November 8, 2017
2 Rural Health Value Vision : To build a knowledge base through research, practice, and collaboration that helps create high performance rural health systems • 3-year HRSA FORHP Cooperative agreement • Partners • RUPRI Center for Rural Health Policy Analysis and Stratis Health • Support from Stroudwater Associates, WIPFLI, and Premier • Activities • Resource development and compilation, technical assistance, research 2
3 Tools and Resources
www.ruralhealthvalue.org |4
5 More tools and resources • Critical Access Hospital Financial Pro Forma for Shared Savings • Critical Access Hospital Financial Pro Forma • Demonstrating Critical Access Hospital Value: A Guide to Potential Partnerships • Care Coordination: A Self-Assessment for Rural Health Providers and Organizations • Guide to Selecting Population Health Management Technologies for Rural Care Delivery • Catalog of Value-Based Initiatives for Rural Providers 5
6 Profiles in Innovation • Medical-Legal Partnership Addresses Social Determinants of Health: FirstHealth of the Carolinas, North Carolina • Rural Accountable Care Organization Care Coordination: MaineHealth ACO, Maine • A Rural Accountable Care Organization: South East Rural Physicians Alliance (SERPA) ACO, Nebraska • Rural Health Networks and New Forms of Governance: Wilderness Health Network, Minnesota • Using Community Connectors to Improve Access: Tri County Rural Health Network, Arkansas • Investing in Population Health: Hidalgo Medical Services, Center for Health Innovation, New Mexico https://cph.uiowa.edu/ruralhealthvalue/InD/Profiles/
Center for Rural Health Policy Analysis Karla Weng, MPH, CPHQ kweng@stratishealth.org www.ruralhealthvalue.org Cooperative Agreement funded by the Federal Office of Rural Health Policy: 1 UB7 RH25011-04. The information, conclusions and opinions expressed in this report are those of the authors and no endorsement by FORHP, HRSA, HHS, or [grantee institutions(s), if necessary/desired] is intended or should be inferred. |7
TASC 90 November 8, 2017 Xi Zhu, PhD University of Iowa College of Public Health RUPRI Center for Rural Health Policy Analysis
61 in 2011 to 923 in 2017 Increase of 2.2 million covered lives in year ending with first quarter of 2017 to reach 32 million In all states; only 15 hospital referral regions not served by an ACO Source: David Mulestein, Robert Saunders, and Mark McClellan (2017) “Growth of ACOs and Alternative Payment Models in 2017,” Health Affairs Blog June 28. accessed June 29: http://healthaffairs.org/blog/2017/06/28/growth-of-acos-and-alternative-payment-models-in-2017. 2
480 Shared Savings ACOs in 2017 9.0 million assigned beneficiaries (in MSSP) in 50 states, Washington D.C., and Puerto Rico 438 Track 1 42 Tracks 2 and 3 45 ACO Investment Model (subset of MSSPs) Plus 44 Next Generation ACOs Source: Centers for Medicare and Medicaid Services (2017) “ Fast facts: Medicare Shared Savings Program ACO,” Baltimore, MD: CMS. accessed August 17, 2017: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf 3
Began with a model relying on physician group practices to control utilization Serve Medicare FFS beneficiaries Not HMOs – beneficiaries have the freedom Not MA – beneficiaries are assigned retrospectively* Control costs while maintaining quality Financial benchmark is set specifically for each ACO Quality metrics and benchmarks are defined for all ACOs * Except for Track 3 of the MSSP 4
Formed by pre-existing integrated delivery networks Physician groups played prominent role in formation and management 13 of 27 included hospitals with quality-based payment experience, and 11 included hospitals with risk-sharing experience; 12 included physician groups with both Managing care across continuum considered very important Source: Abiodun Salako et al (2015) “Characteristics of Rural Accountable Care Organizations (ACOs) – A Survey of Medicare ACOs with Rural Presence” Rural Policy Brief RUPRI Center for Rural Health Policy Analysis, University of Iowa. www.ruprihealth.org 5
$429 million in total savings in 2015 23.6% in 2013 25.8% in 2014 30.4% in 2015 earned shared savings Better financial performance associated with: Longer experience Higher benchmarks Physician-group ACOs Smaller size Sources: CMS (2016) “Medicare Accountable Care Organizations 2015 performance year quality and financial results.” Baltimore, MD: CMS. August 25. S. Lawrence Kocot and Ross White (2016) “Medicare ACOs: Incremental Progress, But Performance Varies.” Health Affairs Blog . September 21. J Michael McWilliams et al (2016) Early Performance of Accountable Care Organizations in Medicare. New England Journal of Medicine . April 13. 6
Success (savings) associated with physician-based Advanced Payment Program ACOs more likely to generate savings No association with ACO size or experience Source: Matthew C Nattinger et al (2016) Financial Performance of Rural Medicare ACOs The Journal of Rural Health 7
Quality scores improved over time, but no direct relationship to savings 91% earned Quality Improvement Reward points in 2015 Better quality performance associated with: Post 1 st year of participation Hospital-system ACOs Larger size Advance Payment Model Postacute follow-up visits Sources: CMS (2016) “Medicare Accountable Care Organizations 2015 Performance Year Quality and Financial Results.” Baltimore, MD: CMS. August 25. S. Lawrence Kocot and Ross White (2016) “Medicare ACOs: Incremental Progress, But Performance Varies.” Health Affairs Blog . September 21. J Michael McWilliams et al (2016) Early Performance of Accountable Care Organizations in Medicare. New England Journal of Medicine . April 13. X Zhu et al (2o17) Better ACO Quality Performance Associated with Hospital-System Sponsorship, Large Beneficiary Panels, and High Postacute Follow-Up Rates. RUPRI Center for Rural Health Policy Analysis at the University of Iowa. October. 8
Rural ACOs performed similarly as urban ACOs on average, but with larger variation FQHC/RHC and advanced practice providers’ provision of primary care services associated with better quality scores (preliminary evidence) Source: X Zhu et al (2o17) Better ACO Quality Performance Associated with Hospital-System Sponsorship, Large Beneficiary Panels, and High Postacute Follow-Up Rates. RUPRI Center for Rural Health Policy Analysis at the University of Iowa. October. 9
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