› presentations › macrasummit2 › lloyd_ms4.pdf Transitioning CAHs to Value -based Care October 12, 2017Transitioning CAHs to Value -based Care October 12, 2017 Danielle Lloyd,

Transitioning CAHs to Value-based CareOctober 12, 2017

Danielle Lloyd, Premier, LLCBrock Slabach, NRHA

Improving the health of the 62 million who call rural America home

NRHA is non-profit and non-partisan

National Rural Health Association Membership

Rural Hospital Overview• Total Rural Hospitals: 1,855

– 1,333 Critical Access Hospitals (CAH)– 522 Prospective Payment System (PPS)

Hospitals (less than 100 staffed beds)• CAH: Paid on Cost Based

Reimbursement, created 1997 from the Balanced Budget Act (BBA)

Critical Access Hospitals(CAH)

• A CAH must have 25 or fewer acute care beds

• It must be located more than 35 miles from another hospital (exceptions may apply)

• It must maintain an annual average length of stay of 96 hours or less for acute care patients

• It must provide 24/7 emergency care services

CAH Quality Reporting• CAH’s voluntary reporting on Hospital

Compare• CAH’s voluntary reporting on HCAHPS• CAH’s exempted from VBP• National standards lack rural measurement

sensitivities

The Starting PointDesired Future State of Measurement of Quality in Rural Hospitals

• Rural metrics (standardization, completeness, consolidation) in:– Patient Satisfaction – Clinical Outcomes – inpatient;

outpatient/ED; transfer; swing beds– Patient Safety – Operations– Community Based Health

(population health)

• Identification of TA needs/processes

NRHA Advocacy Campaign for Quality in 2010

Overarching Principles• Small, rural hospitals should be included in a

robust, rural relevant quality performance measurement program

• Mandate a sophisticated statistical analysis to ensure that low volumes do not significantly reduce measure reliability

• The small, rural measurement system should be adaptable for multiple uses: insurers, regulatory agencies, etc.

Overarching Principles

• Measurement system should include:--clinical processes--Patient Safety--Patient Satisfaction

• Adequate Technical Assistance should be funded to ease implementation of performance measurement programs

• Data Warehouse: non-proprietary

Linking Medicare FFS to Value

Hospitals:• Hospital Value-based Purchasing (HVBP)• Hospital Readmission Reduction Review Program• Hospital-Acquired Condition (HAC) Reduction Program

Physicians:• Physician Value-based Modifier• MACRA

12

2016

30%

85%

2018

50%

90%

Target percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models’ by 2016 and 2018

2014

~20%

>80%

2011

0%

~70%

GoalsHistorical Performance

All Medicare FFS (Categories 1-4)FFS linked to quality (Categories 2-4)Alternative payment models (Categories 3-4)

CAHs

Rural hospitals closing at alarming rate:

Current State

• Two-tiered system with quality and accountability the norm in urban areas and less so in rural ones

• No customized on-ramps or incentives for rural facilities that may want to move toward value

Inpatient hospitals: • Reporting Medicare quality

measures since 2005• Subject to Medicare value-

based payment since 2013• Significant participation in

alternative payment models

CAHs:• Reporting through the MBQIP

under Flex grant program • No required Medicare quality

reporting program• No required Medicare value-

based payment• 150 CAHs in ACOs

Medicare Beneficiary Quality Improvement Project (MBQIP)

• Voluntary CAH participation in quality reporting in Hospital Compare to demonstrate value and cost-effective care

• Core improvement initiatives:Patient Safety:HCP / OP-27: Influenza vaccination coverage among healthcare personnel (Facilities report a single rate for inpatient and outpatient settings)Imm-2: Influenza ImmunizationPatient Engagement:Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Medicare Beneficiary Quality Improvement Project (MBQIP)

Core Improvement Activities Continued:Care Transitions:Emergency Department Transfer Communication (EDTC)Outpatient:OP-1: Median time to FibrinolysisOP-2: Fibrinolytic Therapy Received within 30 minutesOP-3: Median Time to Transfer to another Facility for Acute Coronary

InterventionOP-5: Median time to ECGOP-20: Door to diagnostic evaluation by a qualified medical professionalOP-21: Median time to pain management for long bone fractureOP-22: Patient left without being seen

Medicare Beneficiary Quality Improvement Project (MBQIP)Additional Measures:

Patient SafetyHealthcare Acquired Infections (HAI)StrokeVenous thromboembolism (VTE)Perinatal CareSurgery / Surgical CarePneumoniaFallsAdverse Drug Events (ADE)Patient Safety Culture SurveyOutpatient

NQF Rural Report Recommendations, Sept., 2015

• Make participation in CMS quality improvement programs mandatory for all rural providers but allow a phased approach for full participation across program types

• Use measures for rural providers the explicitly address low case-volume

• Use guiding principles for selecting quality measures that are relevant for rural providers

• Use a core set of measures, along with a menu of optional measures for rural providers

• Consider measures that are used in a Patient Centered Medical Home models

NQF Rural Report Recommendations

• Consider rural-relevant socio-demographic (SDS) factors in risk adjustment

•• Create a Measures Application Partnership (MAP) workgroup Create a Measures Application Partnership (MAP) workgroup to advise CMS on the selection of ruralto advise CMS on the selection of rural--relevant measuresrelevant measures

• Pursue continued alignment of measurement efforts for rural providers

• Fund development of rural-relevant measures. The Committee identified these areas that are especially impactful:• Patient hand-offs and transitions• Alcohol and drug treatment• Telehealth/telemedicine• Access to care and timeliness of care• Cost • Population Health at the geographic level• Advance directive/end-of-life

NQF Rural Report Recommendations•• Participation in VBP and PayParticipation in VBP and Pay--forfor--Performance would include Performance would include

incentive payments, but no penaltiesincentive payments, but no penalties• Offer rewards for rural providers based on achievement or

improvement• Encourage voluntary groupings of rural providers for payment

incentive purposes• Fund additional work to consider how peer groups for rural

providers should be defined and used for comparison purposes

• When creating and using composite measures, ensure that the component measures are appropriate for rural (particularly low-volume) providers

Additional Recommendations—general in nature

• Modify HCAHPS measurement processes to include alternative data collection mechanisms

• Facilitate quicker and broader access to performance scores and to Medicare data for quality improvement purposes

• Facilitate inclusion of CMS data into all-payer databases

CMS Star Rating Program

• CMS Star Rating Program:

Star Rating

Number of hospitals (percent of hospitals rated)

One Star 133 (4%)Two Star 723 (20%)Three Star 1,771 (48%)Four Star 934 (25%)Five Star 102 (3%)

Total Hospitals in Hospital Compare Data Set July, 2016: 4,599 Met Reporting Threshold: 3,658 (80%)Did not meet reporting threshold: 941 (20%) **These are too few measures or measure groups to calculate a Star Rating or measure group score.

CMS Star Rating Program

Star Rating for CAHs:

• Of the 540 CAHs that did have a Star Rating calculated, CMS found a higher average Star Rating among CAHs (mean = 3.31) compared to non-CAHs (mean = 2.99). The range was generally from 2 to 4 stars.

NQF Measures ApplicationPartnership (MAP) Rural Workgroup

• Fulfillment of Sept, 2015 Rural Report Recommendation• Peer group of rural quality experts convened to:

• make recommendations to CMS on rural specific performance measures

• identify the best available measures to assess care and drive improvement in care:

• identify measure gaps,• provide recommendations regarding alignment and

coordination of measurement efforts across programs, care settings, specialties, and the public and private sectors

The stage is ready and the table is set….

CAH VBP Program!

PROPRIETARY & CONFIDENTIAL – © 2017 PREMIER, INC.

26

Danielle A. Lloyd, MPH Vice President, Policy & Advocacy Deputy Director DC OfficePremier, [email protected]

PROPRIETARY & CONFIDENTIAL – © 2017 PREMIER, INC.27

Value-Based Reimbursement Across Payment SilosTr

ack

2Tr

ack

1

Traditional Payment Models

Physician Outpatient Hospital

and ASCs

Inpatient Acute Care

Long Term Acute Care

Inpatient Rehab

SNFs Home Health Care

RBRVS APC MS-DRG MS-DRG RICs RUGs HHRGs

FY2013 PFS-Value modifier;FY2015 - P4R;

FY 2019 – MIPS

P4R in FY2013; ASC VBP impl.

plan submitted to Congress on

4/18/11

VBP commenced

10/1/12

P4R in FY14: VBP test pilot by

1/1/16

VBP test pilot by 1/1/16

VBP starting 10/1/18

VBP impl. plan sent to

Congress3/12. CMS proposes 2016 start

Alternative Payment Models

Post-Acute Care Episode Bundling

Acute Care Bundling

Medical Home

Acute and Post-Acute Care Episode Bundling

Accountable Care Organizations


Trend: Fee for service Population Health Management

Sources:https://innovation.cms.gov/Files/fact-sheet/nextgenaco-fs.pdfhttp://www.markfarrah.com/healthcare-business-strategy/An-Analysis-of-2017-Medicare-Business-Competition.aspxFFS 2015#: 38 (http://www.cbo.gov/sites/default/files/cbofiles/attachments/44205-2015-03-Medicare.pdf) - 7.9M (the ACO population)= 30.1M ACO 2016 #: 8.9M (http://www.hhs.gov/about/news/2016/01/11/new-hospitals-and-health-care-providers-join-successful-cutting-edge-federal-initiative.html)MA 2015#: 17M (http://www.cbo.gov/sites/default/files/cbofiles/attachments/44205-2015-03-Medicare.pdf)

76.4% 75.4%67.9%

64.8%61.7%

54.7% 51.3% 49.5%

23.6% 24.2% 25.6% 27.5% 29.1% 30.9% 32.5% 32.2%

0.0% 0.4%6.5% 7.7% 9.2%

14.4% 16.3% 18.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013 2014 2015 2016 2017

Perc

ent o

f Med

icar

e Be

nefic

iarie

s

Trad

MAACO


Source: http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion/

ACOs by State Commercial and Medicare


MACRA reform timeline(Medicare Access and CHIP Reauthorization Act of 2015)

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Permanent repeal of SGRUpdates in physician payments

TRAC

K 1

20184%

PQRS pay for reporting

Meaningful Use Penalty (up to %)

2017-3.0%

0.5% (7/2015-2019) 0% (2020-2025)

TRAC

K 2

Measurement period

Measurement period

Value-based Payment Modifier

2015-1.5%

2016 & beyond-2.0%

2015-1.0%

2016-2.0%

2018-3.0%

2017-3.0%

2015± 1.0%

2016± 2.0%

2018±2/±4.0%

2017+2/±4.0%

Advanced APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

Merit-Based Incentive Payment System (MIPS) adjustments

2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%

MIPS exceptional performance adjustment; ≤ 10% Medicare payment (2019-2024)

0.75% update

0.25% update


Track 2: 5% Bonus for Advanced APMs

Uses certified EHR technology,

Pays based on MIPS comparable quality measures, and

Total payments exclude payments made by the Secretaries of Defense/Veterans Affairs and Medicaid payments in states without medical home programs or Medicaid APMs.

* Minimum of 25% of Medicare payments must be in APM in all years, unless partial qualifying at with no 5% bonus and a choice of MIPS

Bears more than “nominal” financial risk for losses.

Advanced Alternative Payment Models (APM) Entities Must:

1

2

3

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Measurement periodAdvanced APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024) TRAC

K 2 0.75%

update(2026)

Advanced Alternative Payment Models (APM) as proposed:

Inclusion in Advanced APMs

triggers exclusion from MIPS.

25%50%

75%

2019-20

2021-22

2023 +

Threshold of payments in an Advanced APM

Medicare only

Medicare* and all-payer

Medicare* and all-payer

NextGeneration

ACO

Oncology CareModel

(2-sided risk)

ComprehensivePrimary Care

Plus

ComprehensiveCare for JointReplacement

EpisodePaymentModels

ComprehensiveESRD

(2-sided risk)

Medicare Shared Saving Program(Tracks 2 & 3)

Canceled?

Or, 20% beneficiary count

Or, 35%

Or, 50%


CAHs’ Need for Unique Model

Most CAH’s don’t have the attributed lives needed to achieve the minimum requirements for ACOs Most CAH’s don’t have the attributed lives needed to achieve the minimum requirements for ACOs

Low volume creates high risk in bundled payments that has little risk adjustmentLow volume creates high risk in bundled payments that has little risk adjustment

CAHs’ financial performance can be harmed by entering into population health depending on payer mix and reimbursement arrangements

CAHs’ financial performance can be harmed by entering into population health depending on payer mix and reimbursement arrangements

Existing quality measurement system not practical in rural areasExisting quality measurement system not practical in rural areas

Little available capital to invest or absorb drop in volume Little available capital to invest or absorb drop in volume


What can CAHs do in response to MACRA?

Those small and rural health systems that are not exempt from MACRA have a limited number of responses for helping physicians comply, such as:

• Employ the medical staff and/or build more RHC and FQHC’s to insulate from MIPS

• Default to MIPS and realize employed and independent clinicians are likely to receive lower Medicare reimbursement

• Offer MIPS – APM and help physicians with reporting and scores – for most rural systems this may require partnering with others to meet the minimum requirements

• Offer an Advanced APM – no real great options

Regardless of MACRA decision, be prepared for increasing impact of Value Based Purchasing and Population Health

Rural Policy Research Institute: http://cph.uiowa.edu/rupri/


VBP for Critical Access Hospitals

National

Voluntary

Permanent

Value Based Payment Model

FFS-based; Not MA

No down side risk

Advanced APM

Participating CAHs will be expected to: • Promote-evidence

based medicine and patient engagement;

• Report on quality measures; and

• Coordinate care using telemedicine, remote monitoring or similar technologies.


Eligibility

Affinity groups:• No geographic

restrictions • Must have minimum

number of CAHs to meet statistical thresholds

• Can only participate in one group

• For systems, state-based collaborativesetc.

Regional groups: • If not part of an

affinity group• Geographic area to

be determined by CMS based on participation to ensure statistical thresholds are met

Any Critical Access Hospital can join either:


Approval Process

• Affiliate Groups or individual CAHs seeking to join a Regional Group must submit an application to CMS

• Groups will only be allowed to join on an annual basis

• Individual CAH participants can join/leave groups annually• Incentives support bringing in new CAHs to grow program

• Application will include necessary information to ascertain fitness for participation such as sufficiency of CAH population to meet statistical thresholds, legal entity information, gainsharing methodologies etc.


Timeline

• 5-year contract with two phases• Phase 1- no bonus if you do not turn in measures

• Year 1; 2% bonus on inpatient/outpatient FFS for turning in quality measures

• Year 2; 2% bonus for turning in quality measures

• Phase 2 – if you do not turn in measures you do not get shared savings

• Year 3; shared savings • Year 4; shared savings • Year 5; shared savings

• If you drop out early, you are not eligible for savings and cannot rejoin until that contract would have ended

• If you drop out early and do not continue to report measures, you pay back 1 percentage point of bonus


Quality Measures

• CMS will determine rurally relevant quality measures

• CMS, to the extent practicable, should rely on clinical measures submitted through a qualified electronic health record and episodic claims-based measures

• Benchmarks will be established for Phase 2 to assess minimum performance by the group to obtain shared savings

• Relies on Hospital VBP standards (e.g. performance thresholds announced 60 days in advance)

• Failure to report data on required measures will result in no additional payment or shared savings unless extraordinary circumstance demonstrated

• Measure results will be displayed on Hospital Compare


Payment Benchmarks

• Attribution methodology left up to the Secretary• Establish a Medicare Parts A and B baseline based on

the historical FFS spending of the group• Set a benchmark for the performance period using the

baseline with adjustments for beneficiary characteristics and other factors

• Update the benchmark based on national per capita expenditures

• Rebase the benchmark if contract renewed after 5 years• Savings will be determined based on the difference

between the group’s actual A/B expenditures and the benchmark for the performance year

• 60% share to CAH and 40% share to Medicare


Shared Savings

• After 2 years of quality reporting, CMS will create benchmarks to determine thresholds for receiving shared savings

• There will be no penalties for failure to achieve the quality thresholds or savings

• To the extent that CAHs invest capital in the program and/or reduce volume should be sufficient risk under the Quality Payment Program

• Payments will be made to the legal entity based on the total amount of estimated savings from all participating CAHs

• Distribution to individual CAHs and downstream clinicians will be a function of the legal entity


Gainsharing

• Explicitly permits shared savings and internal cost savings distributions to participants

• Must have a formal legal structure that allows for the distribution of savings

• Must establish agreements up front with gainsharing terms between CAHs and downstream to clinicans

• Must describe methodology to CMS in application

• Must include quality metrics to determine how to share the funds between CAHs

• CMS will provide results of claims-based quality and efficiency measures at the clinician level to assist in gainsharing calculations


Data Access

• CMS will provide Medicare Parts A, B and D claims data to each participating CAH on a monthly basis similar to other programs

• CMS will provide data on quality measure results to participants at both a facility level and clinician level


Legal Issues

• Establishes an appeal process for achievement of quality thresholds and shared savings

• Authorizes the waive Stark, Anti-kickback and Civil Monetary penalties as necessary


Evaluation and Reports

• EVALUATION.—The Secretary shall evaluate the CAH VBP Program, including the extent to which payments under the Program have resulted in—

A. improved quality and efficiency of care;B. improved health outcomes; andC. improved access to care by applicable beneficiaries.

• REPORTS.—Not later than June 30 of each year, beginning with 2020, the Secretary shall submit to Congress a report on the results of an evaluation conducted including recommendations for legislation or administrative action.


Advocacy

• Know the Member of Congress• District and State • Committee • Healthcare Interests • Hospitals affected/ constituent needs

• Personal Experience• Why are quality programs effective?• How does increased quality affect

patients?

• How does this help the federal government?• Quality care equates to lowers costs and

readmission rates • Economic impact of keeping Critical

Access Hospitals open in rural communities

PROPRIETARY & CONFIDENTIAL – © 2017 PREMIER, INC.

©2016 Premier Inc. Proprietary and confidential

Danielle Lloyd, MPHVP, Policy & AdvocacyDeputy Director, DC [email protected]

www.PremierInc.com

Documents

› presentations › macrasummit2 › lloyd_ms4.pdf Transitioning CAHs to Value -based Care October 12, 2017Transitioning CAHs to Value -based Care October 12, 2017 Danielle Lloyd,