PRICI CING METHOD ODOL OLOG OGY FOR CL CLINICIANS AN S AND D ADM ADMINIS ISTRATORS June une 2018 2018
Introduct ction ons Steve Farmer, MD, F FACC, CC, F FASE ASE • Senior Medical Officer • CMS Innovation Center • Practicing Cardiologist Elizabeth Cur Currier, MBA/MPH PH, L LSSG SSGB, FACM CMPE PE • Physician Practice Administrator • Senior Improvement Advisor • CMS Innovation Center 2
Webcast O Outline • BP BPCI CI Adv Advance ced M d Model Co Conce cept Revi view • Clin linic ical E l Epis isodes • Target P Pricing Methodol ology gy: Acute C e Care Hospital Ho al ( (ACH) • Target P Pricing Methodol ology gy: Physician G Grou oup Practice ce ( (PGP) P) • Reco conciliation • Summa mary • Addition onal al R Resou ources es 3
BP BPCI CI AD ADVAN ANCE CED M MODEL L CONCE CEPT 4
BP BPCI CI Adv Advanc anced T ed Tes ests a D a Differ eren ent Payment Approa oach ch Establishes an Shifts emphasis from individual “accountable party” services towards a coordinated Clinical E Episode Clinical Episodes are assessed on the quality and cost of care 5
Why C Clinical Ep Episod ode B Bundles? ? Pr Promote tes a patient-centered approach t to care Employs Clin inical l Epis isodes t that are clin linically in intuit itiv ive, concrete, a and a actionable Applies lessons learned f Ap from Bundled P Payments for Care Imp mprovemen ent ( (BPCI CI) Provide des important A Advanc nced d Alternative P Payment Model (Ad Advanced APM APM) and Merit-Ba Based ed Incentive e Payment System ( (MIPS) ) APM o opportu tunity for specialty p physicians 6
How Doe oes B BPC PCI A Advance ced Wor ork? Clinical E Episod ode tr e trigger ered ed b by ei eith ther er a an inpati tien ent t (IP) ) hos ospital stay (Anch chor S Stay) or ) or ou outp tpati tien ent ( t (OP) proced cedure ( e (Anchor P Proced ocedure) Clinical al Ep Episo sode a attributed to PGP or A ACH CH Car are p provided u under stan andar ard f fee-fo for-ser ervi vice ce ( (FFS) paymen ents. At th t the e en end of of ea each ch P Per erformance e Per eriod, , quality ty a and cos ost t per erformance a e are a e asses essed ed. 7
CL CLINICA CAL E L EPISO SODES 8
Clinical Ep Episod ode L Length IP P Clinical Ep Episode: : Anchor Stay Anchor 90 Days EPISODE + 90 days beginning the Stay day of discharge OP P Clinical Ep Episode: : Anchor Procedure Anchor 90 Days + 90 days beginning on the EPISODE Procedure day of completion of the outpatient procedure 9
Se Servi vice ces I Incl cluded i in the Clinical Ep Episod ode • IP or OP hospital services that • Clinical laboratory services comprise the Anchor Stay or Anchor • Durable medical equipment (DME) Procedure (respectively) • Part B drugs • Physicians’ services • Other hospital OP services • IP hospital readmission services • Long-term care hospital (LTCH) services • Hospice services • Inpatient rehabilitation facility (IRF) services • Skilled nursing facility (SNF) services • Home health agency (HHA) services 10
Readmission on Ex Excl clusion ons Single list of e excluded M MS-DRGs a apply ly to Cli linical Epis isodes, whic ich will ill inc nclude 132 132 MS-DRG RGs: Transplant & Tracheostomy Trauma Cancer (when cancer is explicitly indicated by MS-DRG) Ventricular Shunts 11
Se Servi vice ces Ex Excl cluded f from om the Clinical Ep Episod ode Part B B ser ervice ces: s: Blanket e exclusions: • Excluded only if incurred • Blood clotting factors to during an excluded ACH control bleeding for admission or readmission hemophilia patients • BPCI Advanced will not • New technology add-on follow the clinically related payments under the IPPS criteria guiding Part B • Payments for devices, status exclusions used in BPCI indicator H, with pass- through payment status under the OPPS 12
Elig ligib ible le A ACHs • Not t all ACHs m may p parti tici cipate i e in BPCI A Advance ced • Critical Access Hospitals • Selected Cancer Hospitals not participating in the Prospective Payment System • Inpatient Psychiatric Facilities • Hospitals in Maryland • Hospitals participating in the Rural Community Hospital demonstration • Rural Hospitals participating in the Pennsylvania Rural Health Model • Hos ospital i is CJR parti tici cipant • CJR episodes take precedence over BPCI Advanced for Major Joint Replacement of the Lower Extremity (MJLRE) Clinical Episodes • No MJLRE Target Price will be provided at CJR hospitals • CJR hospitals may participate in non-MJLRE Clinical Episodes 13
Benefici ciary Ex Excl clusion on C Criteria Ben enefici iciaries a are e e excl cluded ed if: • They are covered under United Mine Workers or managed care plans (e.g. Medicare Advantage, Health Care Prepayment Plans, or cost-based health maintenance organizations) • They are eligible for Medicare on the basis of end-stage renal disease (ESRD) • They die during the Anchor Stay or Anchor Procedure • They are not eligible for Medicare Part A, enrolled in Part B for the entire Clinical Episode • Medicare is not the primary payer 14
TARGET ET PR PRICING M MET ETHODOLOGY ACU CUTE CAR CARE H HOSPITALS ALS (ACH CHs) 15
BPC PCI A Advance ced Es Essential Features 1. Encourage both high and low cost providers to participate 2. Reward Participants’ improvement over time 3. Adjust for patient case mix that is outside of providers’ control 4. Allow for trends in Clinical Episode spending by hospital peers 5. Promote Medicare savings while maintaining high quality care 16
ACH Bench chmark P Price ce The Hos ospital’ l’s B Ben ench chmark P Price ce accounts for three central factors: 1. Patient case-mix 2. Historic Medicare FFS expenditures during the ACH’s Baseline Period 3. Patterns of spending relative to the ACHs peer group 17
Patient C Case Mix is Acc ccou ounted for or I In Mult ltip iple le W Ways Med edicare S e Severity ty - Diagnos osis Rel elated ed G Grou oup ( (MS-DRG) an and Compreh ehen ensive e - Ambula latory P Proced cedure C Cod ode e (C-APC) a ) assignmen ent • Hospital DRG triggers are stratified by medical severity [e.g., with complication or comorbidity (CC) or with major complication or comorbidity (MCC)] • Outpatient C-APC triggers are designed to group Clinical Episodes by similar resource use Pati tien ent ch t characteristi tics cs • Demographic characteristics (e.g., age, gender) • Long-Term Institutional Status • Dual Eligibility for Medicare and Medicaid • Hierarchical Condition Categories, Interactions, and counts • Recent Resource Use 18
Hierarch chical Con ondition on Categor ory ( (HCC) Cod oding Hier erarch chical C Con onditi tion C Categ egor ories ( (HCC): ): • The CMS-HCC model groups individual diagnoses by similar diagnoses and illness severity. Individual HCC categories are used to account for clinical conditions in the BPCI Advanced model. Clinician Tips • Co Code all de all pertine pertinent t HCCs HCCs for conditio onditions ns acti actively ely t treating ting o Example: An orthopedist need not code for CHF if it is not actively managed during the clinical episode • All All HCC HCC d diagnoses iagnoses recorded ded i in th the e calendar alendar year ear a are included, e included, regardless dless of of who o codes odes th them em or or whe here e they they are e coded oded o Example: If another clinician indicates active treatment of CHF within the same 90 days , it will also apply to risk adjustment for the orthopedic episode 19
Bun Bundled ed Cl Clini nical E Episo sodes Co es Compar are e Peer eers o on n the e Ba Basis o s of the T he Type a e and Q Quanti tity o of Ser Services es Provided Hos ospital A A: Hos ospital B B: Excellent Outcomes Excellent Outcomes Low Unit High Volumes Unit Volumes Patient Patient Te Testing Testing Te Inpatient D t Days Inpatient D t Days Post-acut Po ute C Care Days Po Post-acut ute C Care Days Readmissions Readmissions 20
CMS Standardization Methodology* • CMS adjustments are re removed when calculating historical Clinical Episode costs and making comparisons to other ACHs • Compares the intensity of services provided, independent of context • These adjustments are reapplied ed in the final step of setting ACH benchmarks • Accounts for context when setting the final target price *https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and.-Reports/Medicare- 21 Geographic-Variation/Downloads/Geo_Var_PUF_Technical_Supplementpdf
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