OP OPERATIO IONALIZ IZIN ING B BPCI I ADVA VANCED MAY 2018 2018
Intr troducti tions Steve F Farm rmer, M , MD, F , FACC, F , FASE • Senior Medical Officer • CMS Innovation Center • Practicing Cardiologist Elizabeth Curri Currier, M , MBA/MPH, L LSSGB, F , FACMPE • Physician Practice Administrator • Senior Improvement Advisor • CMS Innovation Center 2
Webcas ast Ou Outline • The CMS Innovation Center • Review of BPCI Advanced Features • Application to the Model • Participation in the Model Common Challenges • Strategies for Success • • CMS Innovation Center Partnership • Reconciliation Process • Summary and Conclusions 3
INTROD ODUCTION ON The CMS Innovation Center and BPCI Advanced 4
The CM he CMS I Inn nnovation Cen Center er • As part of the Centers for Medicare & Medicaid Services (CMS), the CMS Innovation Center provides national leadership in the transition from volume to value • The center tests innovative payment and service delivery models that reduce costs while preserving or enhancing quality • Guiding principles Patient centered care • Provider choice and incentives • Choice and competition in the market • Transparent model design and evaluation • Benefit design and price transparency • Small scale testing • 5
Model Sce cenarios f for S Succe ccess 1 Qua uality Cost 2 Qua uality Cost 3 Bes est Case Qua uality Cost 6
REVI EVIEW EW Bundled Payments for Care Improvement Advanced 7
BPC PCI A Advanced T Tests a a Different Payment A Approac ach Shifts emphasis from in indiv ivid idual l Establishes an servi vice ces towards a coordinated “accountable p e party” clinic ical e al episod ode Clinical episodes are assessed on the quality ty a and c cost of care 8
BPC PCI A Advanced i is Different T Than B BPC PCI • Streamline ined de design One model, 90-day episode period • Single risk track • Inpatient and Outpatient episodes • Preliminary target prices provided in advance • Payment tied to performance on quality measures • • Greater focus on ph physic icia ian n eng ngagement a and l nd learni ning ng • Designed as an Advanc nced A d APM under the Quality Payment Program 9
Who L Leads Clinical Ep Episodes? Physician G n Group up Ac Acut ute C Care Ho e Hospitals s Practices ( s (PGP GPs) (ACHs Hs) 10
Participants M May Work w with a a Convener A C Conven ener er is a a Medicare-enrolled pr provide der o or suppl upplier or a an n entity t tha hat is no not enr nrolle led i d in n Medic dicare. Conven ener ers m may: • Facilitate participation by smaller PGPs or ACHs • Provide data and analytic feedback • Offer logistical and operational support • Bear financial risk to CMS under the Model 11
Quality M Measures Will include clai laims-based ed Addit ition ional me al meas asures with measures es t through gh 2020 varying reporting mechanisms may be added in the future 12
Initial Quality M Measures Qua uality m measu sures es for: All-cause Hospital Readmission Measure Al All (Natio ional l Qualit lity Forum [NQF] #1789) 1789) Clinical Care Plan Epi piso sodes des (NQF # #0326) 0326) Perioperative Care—Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF # #0268) 0268) Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF # #1550) 1550) Spec ecific Clinical Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery Epi piso sodes des (NQF # #2558) 2558) Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF QF #2881) 2881) AHRQ Patient Safety Indicators (PS PSI I 90) 13
Setting B Bench chmark P Price ces Ph Physic ician Group up P Practice Hospital al’s Benchmark P ark Price: (PG PGP) P) Benc nchmark Price: Patient case-mix 1. 1. Anchored on hospital Peer group trends 2. 2. Accounts for PGP– specific historical Historic efficiency 3. practice pattern 14
PGP P PG P Prici cing Ur Urban an Acad ademic ic M Medic ical al Rura ral Cente ter ( (AMC) ACH: $20,000 PGP: $22,000 ACH: $18,000 ACH: $25,000 PGP PGP PGP: $20,000 PGP: $27,000 KEY POI POINTS 1. PGPs may practice at multiple hospitals 2. Hospital pricing varies 3. Limited time PGP adjustment, anchored on hospital price 15
BPCI BP CI A Adv dvanc anced ed Prec eced eden ence R Rul ules es 1 At Attendi nding ng P PGP 2 Opera rating ng P PGP 3 ACHs Hs 16
Pati tient A Attr tributi tion: M Multi tiple P PGPs, B Both th Participating i in Pneumonia Clinical Ep Episode Clinic ical E Epis isode Attribution Partic icip ipatin ing P g PGP 1 PGP1 PG P1 Non-Partic icip ipatin ing A g ACH Non-Partic No icip ipatin ing PGP GP 2 2 KEY POINT NTS Partic icip ipatin ing g 1. Multiple PGPs may exist at an PGP GP 3 3 ACH PG PGP3 P3 2. All PGPs need not participate 3. Attending identified through UB-04 and Part B Claim 17
Patient A Attribution: A ACH and Multiple PG PGPs, Participating i in Pneumonia Clinical Ep Episode Clinic ical E Epis isode Attribution Partic icip ipatin ing P g PGP 1 PGP1 PG P1 Partic icip ipatin ing A ACH No Non-Partic icip ipatin ing PGP GP 2 2 ACH Partic icip ipatin ing g KEY POINT NTS PGP GP 3 3 1. ACHs and PGPs may participate 2. If ACH participates, all clinical PGP3 PG P3 episodes are in the model 18
Patient A Attribution: A ACH and Multiple PGPs, D Dif ifferent C Clin linic ical Epis isodes Clinic ical E Epis isode Attribution Partic icip ipatin ing P g PGP 1 PGP1 PG P1 Partic icip ipatin ing A ACH Non-Partic No icip ipatin ing PGP GP 2 2 ACH Partic icip ipatin ing g KEY POINT NTS PGP GP 3 3 1. PGPs and ACH may participate in different episode categories PG PGP3 P3 2. Exclusive participant would get all episodes, subject to trigger rules 19
APPLICATION TO THE MODEL 20
Applicants W Will Rece ceive Data i in Advance • CMS will provide preliminary target prices to applicants in May 2018 • Applicants who submit a Data Request and Attestation form o Three years of aggregate (summary) and/or raw (beneficiary line- level) Historical Claims data for the Medicare beneficiaries who would have been included in a Clinical Episode and attributed to the applicant • Convener appl pplicants receive target prices for all of their episode initiators (EIs) • No Non-convener appl pplicants receive their own target prices 21
Clinical Ep Episode S Select ction • Participants will enter into an agreement with CMS May be renewed annually • Commits to selected Clinical Episodes until the start of the • following Agreement Term • Episode selections must be submitted to CMS by August 1, 1, 2018 2018 22
Considerati tions f for P Parti ticipation • Are there other potential Participants for the same Clinical Episode at the same ACH? • Are there clear opportunities for improvement within the model? • Can operational investments be spread across multiple clinical episodes? ? ? • Can Participants safely assume financial risk? • Does it make sense to work with a Convener? • Would Participants qualify for incentive payments as a Qualifying APM Participant in the Quality Payment Program? 23
PARTIC ICIP IPATIO ION I IN THE M E MOD ODEL EL 24
Exam ample S Strategy: y: Data T Transpar arency • Utilize care management software to share data between hospital and PAC providers; include physician, hospital, and regional-level data. • Create patient dashboards with real-time data that physicians and partners can easily access. • Utilize a data analytic tool to help staff identify patients needing additional care during their SNF stay. 25
Example S Str trategy: Uti tilize a a Risk k Asse Assessment T Tool • Incorporate a readmission prediction tool into your electronic health record (EHR) for both high and middle risk patients. o Use a tool, which includes a section for identifying patient risk for readmission, in tandem with "At-Risk" meetings. o Use a tool, which includes care pathways and “change in condition” tools, to manage care and prevent readmissions. o Use an index scoring tool for risk assessment of death and readmission. • Use a n analysis platform, which assists with risk assessment and discharge planning decisions. 26
Exampl ple S Strategy: Redes edesign Car Care e Pa Pathway ays • Update and simplify patient forms/checklists to ease pre- screening and post-acute care transfer. Support consistent use by all providers. • Provide telephone number/toll-free hotline for patients to call with questions or concerns post-discharge to reduce readmissions. • Modify clinical pathways to incorporate therapy interventions. 27
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