UNBUNDLING THE CARDIAC BUNDLE Success with Episode Payment Models - PDF document

4/12/2017 UNBUNDLING THE CARDIAC BUNDLE Success with Episode Payment Models April 13, 2017 Eric Rogers X. Lucy Zhang, RN David W. Stein, MD, FACS, ENT Senior Managing Consultant Senior Consultant Physician and President of erogers@bkd.com xzhang@bkd.com Strategic Medical Consultants 1

4/12/2017 TO RECEIVE CPE CREDIT • Participate in entire webinar • Answer polls when they are provided • If you are viewing this webinar in a group  Complete group attendance form with • Title & date of live webinar • Your company name • Your printed name, signature & email address  All group attendance sheets must be submitted to training@bkd.com within 24 hours of live webinar  Answer polls when they are provided • If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar UNBUNDLING THE CARDIAC BUNDLE Success with Episode Payment Models April 13, 2017 Eric Rogers X. Lucy Zhang, RN David W. Stein, MD, FACS, ENT Senior Managing Consultant Senior Consultant Physician and President of erogers@bkd.com xzhang@bkd.com Strategic Medical Consultants 2

4/12/2017 AGENDA • Ruling Overview & Implications • Key Elements • Implications & Next Steps • Q&A EPISODE PAYMENT MODELS OVERVIEW 3

4/12/2017 THE FUTURE IS UNCERTAIN • Latest updates “ We insist CMMI stop experimenting with Americans’ health & cease all  Implementation date delayed from current & future planned mandatory July 1 to October 1 initiatives within the CMMI”  CMS is taking comments regarding further delaying until January 1, 2018 – Letter from Tom Price to CMMI in September 2016 Best Time to Act is Now Regardless of political climate, quality ‐ based reimbursement is here to stay. Providers who prepare early are better poised to succeed EPISODE PAYMENT MODELS (EPMS) CREATED FOUR MODELS Acute Myocardial Coronary Artery Cardiac Rehabilitation Surgical Hip & Femur Infarction (AMI) Bypass Graft (CABG) (CR) Incentive Fracture Treatment Model Model Payment Model (SHFFT) Model Three AMI MS ‐ DRGs Six MS ‐ DRGs Four HCPCS Three MS ‐ DRGs •280 •281 • 93797 • 231 • 480 •282 • 93798 • 232 • 481 Six PCI MS ‐ DRGs (with AMI diagnosis in principle or • G0422 • 233 • 482 secondary positions on IPPS claim) • G0423 • 234 •246 • 235 •247 •248 • 236 •249 •250 •251 4

4/12/2017 EPM DEFINITION & TIMELINE • Five ‐ year model from October 1, 2017 to December 31, 2021 • Episode starts on admission & ends 90 days after day of discharge • Hospitalization must be at a participant hospital & patient must be eligible Medicare beneficiary discharged under MS ‐ DRGs within EPM scope Voluntary Downside downside risk begins risk begins SCOPE OF EPM SERVICES & ITEMS Included Excluded IP hospitalization (including related readmissions) • Hospital readmission DRGs related to •  Oncology • IRF  Trauma medical • SNF  Surgery for chronic & acute conditions not likely • IP psych facility related to care provided during EPM episode Home health agency • • Part B services not likely related to care provided • Outpatient services during EPM episode • Independent OP therapy • Drugs outside of EPM definitions (hemophilia clotting • Clinical lab services factors) DME • • IPPS new technology add ‐ on payments for drugs, • Physician services technologies & services • Part B drugs • OPPS transitional pass ‐ through payments for medical • Hospice devices Hospitals are financially accountable for all related Part A & B claims that occur during episode, significant amount of which fall in post ‐ acute phase 5

4/12/2017 EPM FINANCIAL ACCOUNTABILITY • EPMs will operate under retrospective & two ‐ sided risk model with hospitals bearing financial responsibility CMS gets their  Hospitals & other providers will be paid under FFS, per cut – usual $50M total CMS  Reconciliation process will be performed at end of each savings during five ‐ EPM performance year where hospital’s financial year cardiac performance will be compared against quality ‐ adjusted bundles target price • If hospital’s spending exceeds target price, repayment is owed to CMS • If hospital’s spending is less than target price, reconciliation payment will be paid to hospital from CMS HOSPITAL SELECTION 98 Using random selection, three MSA groups AMI/CABG MSAs were chosen 1. AMI/CABG • 98 MSAs • 1,127 hospitals 2. CJR/SHFFT • 67 MSAs • CJR = 792 hospitals* • SHFFT = 866 hospitals 3. AMI/CABG/CJR/SHFFT • 17 MSAs • 195 hospitals • AMI & CABG are implemented in same MSAs • SHFFT is implemented in same MSAs as CJR, mostly to same providers 148 out of 374 MSAs, or 40% of MSAs, are subject to mandatory bundles *CJR providers list updated January 1, 2017 6

4/12/2017 CARDIAC BUNDLE CHALLENGES COMPARED TO CJR • AMI/CABG beneficiaries have more chronic diseases • AMI/CABG beneficiaries have higher rates of mortality & readmissions • AMI episodes require different clinical pathways (medical, interventional) & have greater variation in these pathways • AMI episodes are emergent cases • Hospitals may not offer all services required to treat AMI • Three ‐ fourths of CABG episode spending occurs in acute ‐ care phase Compared to CJR, EPM beneficiaries will be more complex to care for & higher in acuity HOW TO WORK WITH PHYSICIANS TO MANAGE RISK • Protocol development • Standardization of care pathways 7

4/12/2017 EPM FINAL RULING – KEY ELEMENTS KEY ELEMENTS OUTLINE • Major changes from proposed rule • Transfer policies • Composite quality score • EPM benchmark prices • How reconciliation & repayments are calculated • EPM collaborators & gainsharing • EPM waivers • Cardiac Rehabilitation Incentive Model 8

4/12/2017 MAJOR CHANGES FROM PROPOSED RULE • Delayed downside risk by one year  EPM participants will not have mandatory downside risk until episodes starting January 1, 2019. Optional downside risk is available starting January 1, 2018 • Eliminated chained ‐ anchor hospitalizations transfer scenario  Hospitals that transfer EPM beneficiary to another hospital during anchor hospitalization will result in canceled episode (if applicable) for initial hospital • New voluntary CABG quality metric  STS CABG composite score • Cancels EPM episode if beneficiary dies during episode  Originally CMS only canceled episode if death occurred during anchor stay • Greater protections for low ‐ volume hospitals  Created “EPM ‐ volume protection hospitals” category (hospitals where historical EPM volume is at or below 10th percentile of all hospitals in same MSA eligible to be in that EPM), who will have same lower stop ‐ loss limits as rural hospitals, SCHs, MDHs & RRCs • Waived definition of “qualified physician” for cardiac rehab model  Nonphysician practitioners (PA, NP, CNS) are now qualified for specific functions • More flexibility to use CR incentive payments  May use CR incentive payments to provide beneficiaries with more than just transportation TRANSFER POLICY SUMMARY Scenario Episode Initiation & Attribution Policy Initiate AMI of CABG episode based on anchor hospitalization • No transfer (participant) MS ‐ DRG • Attribute episode to initial treating hospital No transfer (nonparticipant) • No AMI or CABG episode initiated Inpatient to inpatient • Initiate AMI or CABG episode based on MS ‐ DRG at i ‐ i transfer (i ‐ i) transfer hospital (nonparticipant to participant) • Attribute episode to i ‐ i transfer hospital Inpatient to inpatient transfer • Cancel AMI episode (participant to nonparticipant) • No other AMI or CABG episode is initiated • Cancel AMI episode at initial treating hospital. Initiate AMI or Inpatient to inpatient transfer CABG episode at i ‐ i transfer hospital (participant to participant) • Attribute episode to i ‐ i transfer hospital Outpatient to inpatient (o ‐ i) • Initiate AMI or CABG episode based on anchor hospitalization transfer (nonparticipant to participant MS ‐ DRG at o ‐ i transfer hospital or participant to participant) • Attribute episode to the o ‐ i transfer hospital Outpatient to inpatient transfer • No AMI or CABG episode is initiated (participant to nonparticipant) If participant hospital does not admit or discharge beneficiary, episode will not occur 9