Quality Methodology Center for Medicare and Medicaid Innovation - PowerPoint PPT Presentation

Quality Methodology Center for Medicare and Medicaid Innovation (CMS Innovation Center) August 2018

Webcast Outline • BP BPCI CI Adv Advance ced O d Overvi view • Qua uality M Measurement • Application of Q Quality M Mea easu sures • Summa mary 2

BPCI Advanced Overview 3

BPCI Advanced Tests a Different Payment Approach Establishes an Shifts emphasis from individual “accountable party” services towards a coordinated Clinical Ep Episode Clinical Episodes are assessed on the quality and cost of care 4

Why Bundled Clinical Episodes? Prom omotes es a a patien ent-cen enter ered ed approac oach t to care b e by: Employing C Clinical E Episodes that are clinically i intuitive, con oncr crete, a , and acti ction onable Applying l les esson ons l lea earned from Bundled ed P Paymen ents ts f for or Care e Im Improvement ( (BPCI) i initiative Providing i import rtan ant A Advanced A Altern rnative P Paym yment Model (Adv dvanced A d APM) an and Merit-Based ed I Incen centi tive P e Payment S t System (MIPS) A ) APM op oppor ortu tuniti ties f for or s speci ecialty ty physici cians 5

How is BPCI Advanced Different Than BPCI? • St Streamline ned d desi sign o One Model, all 90 day episodes o Single risk track o Payment is tied to performance on clinically relevant quality measures o Target Prices are largely set in advance • Greater focus on physici cian en engagem emen ent a t and lea earnin ing • Designated as an Advanced ed AP APM under the Quality Payment Program 6

Quality Measurement 7

The CMS Innovation Center The e Innovati tion on C Cen enter er t tes ests ts innovati tive p payment a t and ser ervi vice ce d del eliver ery mod odels els th that t are i e inten ended ed to o red educe e ce expen enditu tures w while e preser erving or or enhan ancing q qual ality. 1 Quality Expenditur Ex ures 2 Quality Ex Expenditur ures 3 Bes est C Cas e Quality Expenditur Ex ures 8

Premise of Value Value = Expenditures and Quality • The Positive or Negative Total Reconciliation Amount will be adjusted based on quality ty p per erform rmance • The adjustment is limited to a maximum of 10% in 2018 and 2019 9

How Does the Quality Payment Program Benefit Clinicians and Patients? Clinicians Patients • Increases access to • Streamlines reporting better care • Standardizes measures • Enhances coordination (evidence-based) through a patient- • Eliminates duplicative centered approach reporting which allows • Improves results clinicians to spend more time with patients • Promotes industry alignment through multi- payer models • Incentivizes care that focuses on improved quality outcomes 10

Quality Measures Correlation to Clinical Episodes Model Years 1 & 2 Quality Measure Guidance Applicable Clinical Episode Categories NQF #1789 All-cau ause H e Hos ospital al R Read admission on M Meas asure All Inpatient and Outpatient Clinical Episodes QPP #0458 NQF #0326 Ad Advance Ca Care P Plan* All Inpatient and Outpatient Clinical Episodes QPP #047 Hospital-Level R Risk-Stan andar ardized ed C Complication • Double Joint Replacement of the Lower Rate ( (RSCR) F Follo lowin ing E Electiv ive Pri rimary ry T Total H l Hip p NQF #1550 Extremity: MS-DRGs: 461, 462 Arthroplas asty ( (THA) a and/or or T Total al K Knee ee • Major Joint Replacement of the Lower Extremity: Arthroplasty ( (TKA) A) MS-DRGs: 469, 470 Hospital 3 30-Day, y, A All-Cau ause, e, R Risk-St Standardized ed NQF #2558 Mortal ality R Rate ( e (RSMR) F Following C Coron onar ary CABG: MS-DRGs: 231, 232, 233, 234, 235, 236 Art rtery ry B Bypa pass Graft S Sur urgery ry ( (CABG) Exces ess D Days in Ac Acute e Care af e after er H Hospital alization on NQF #2881 AMI: MS-DRGs: 280, 281, 282 for Ac Acute M e Myocar ardial al I Infar arct ction on ( (AMI) • All Inpatient and Outpatient Clinical Episodes Clinical Episodes CMS P Patien ent S Saf afety I Indicator ors NQF #0531 • The CMS PSI 90 will variably apply to individual clinical episodes. Performance on this measure is specific to the clinical episode. (Only included ones that are available) 11 *NQF-endorsed at Physician level; others lacking asterisk are endorsed at the Hospital level.

Quality Measures Correlation to Clinical Episodes Model Years 1 & 2 Quality Measure Guidance Applicable Clinical Episode Categories Back and Neck Except Spinal Fusion (Inpatient and Outpatient) [2] MS-DRGs: 518, 519, 520; HCPCS: 62287, 63005, 63011, 63012, 63017, 63030, 63040, 63042, 63045, 63046, 63047, 63056, 63075 Cervical Spinal Fusion: MS-DRGs: 471, 472, 473 Combined Anterior Posterior Spinal Fusion: MS-DRGs: 453, 454, 455 Periop oper erative CABG: MS-DRGs: 231, 232, 233, 234, 235, 236 Care: e: S Select ction on Double Joint Replacement of the Lower Extremity: MS-DRGs: 461, 462 of P Prop ophylact ctic c NQF #0268; Antibioti tic: c: F First QPP #021 Hip and Femur Procedures Except Major Joint: MS-DRGs: 480, 481, 482 or S Seco cond Gen eneration on Lower Extremity and Humerus Procedure Except Hip, Foot, Femur: Cephalosporin* MS-DRGs: 492, 493, 494 Major Bowel Procedure: MS-DRGs: 329, 330, 331 Major Joint Replacement of the Lower Extremity: MS-DRGs: 469, 470 Major Joint Replacement of the Upper Extremity: MS-DRG: 483 Cardiac Valve: MS-DRGs: 216, 217, 218, 219, 220, 221, 266, 267 *NQF-endorsed at Physician level; others lacking asterisk are endorsed at the Hospital level. 12

Quality Measures Submission • The Five Inpatient Quality Reporting Measures will be calculated by CMS from Administrative Claims (#1789; #1550; #2558; #2881; #0531). • The Perioperative Care (#0268) measure will be calculated from MIPS QCDR submission. • The Advance Care Plan (#0326) will be calculated based on submitted claims, from ANY Physician or Advanced Practice Provider (regardless of BPCI Advanced participation) for the episode time period and nine months prior. • Performance data is calculated based on Calendar Year data beginning with CY 2019. 13

Quality Data Timeline • The first two Performance Periods are a staggered approach where quality performance is accrued but not initially applied Performance Period 1 Performance Period 2 (10/1/18 – 6/30/19) (7/1/19 – 12/31/19) Model Year 1 Model Year 2 Model Year 3 Oct. 1, 2018 – Jan. 1, 2019 – Dec. 31, 2019 Jan. 1, 2020 – Dec. 31, 2020 Dec. 31, 2018 July 1, 2020 Jan. 1, 2020 Jan. 1, 2019 July 1, 2019 2018 Benchmark data based on CY 2017 Performance Period Adjustments for PP1 & PP2 14

Quality Measures: Model Years 3 – 6 Will include claims ms-based Ad Additional m measures with measures t thr hroug ugh 2020 2020 varying reporting mechanisms may be added thereafter 15

CMS Plans to Refine Measures for Model Year 3 (2020) The e Innovati tion Cen Center is working with c clinicians t s to r refine t the e quality m y measures es a aligned ed wi with t the mod odel el. Aspiration onal al G Goa oals: • Measures should be evidence based and have a clear relationship to quality; • Measure sets should be timely, actionable, and should reflect care delivered within the model; • Measure selection should minimize participant burden; • Data are readily available for incorporation into the model. 16

Application of Quality Measures 17

Quality Measure Performance Positive or Negative Reconciliation Amount EI #2 EI #1 + + + Q C C S Q Q S S CABG CA BG CA CABG BG Qual ality Qual ality Compared to Clinical Episode Performance Clinical Episode Performance Clinician Tip Not all of the measures apply to all of the Clinical Episodes. • Quality measure performance is only compared across the same • clinical episodes. 18

Quality Measures Assessed by Clinical Episode Performance is relative to peers • For each Quality Measure, raw data is converted into scaled scores • using deciles 19

Clinical Episode Quality Scores are Combined into a Composite Quality Score (CQS) Episod ode e Initiator In (PGP/ACH) Composite Quality Score is Calculated at the Episode Initiator Level 62 Quality Score is Calculated at the Clinical Episode Level COPD OPD CHF HF TKA KA Sep epsi sis 60 40 80 70 20

Composite Quality Score (CQS) Converted to CQS Adjustment Percentage Composite Quality Adjustment Score Percentage 0.67 3% 21

Application of Quality Measures 22

Payment Adjustment for Quality Step For each Quality Measure, convert raw data into scaled scores based on 1 national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50 th percentile values 23

Payment Adjustment for Quality Step For each Quality Measure, convert raw data into scaled scores based on 1 national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50 th percentile values Step Roll up scaled quality points into a quality score at the Clinical Episode 2 level 24