National Provider Trends & Strategic Considerations Around Value Based Purchasing

Transcription

1 National Provider Trends & Strategic Considerations Around Value Based Purchasing Melinda S. Hancock, FHFMA,CPA Partner, DHG Healthcare Chair, HFMA Southern California HFMA August 2015

2 Objectives of Today s Presentation Identify key industry trends Details of the Mandatory Programs Describe how these trends impact other segments Discuss strategies for success in the current healthcare environment. 2

3 Go Beyond the Status Quo It isn t the mountains ahead to climb that wear you out; it s the pebble in your shoe. Muhammad Ali 3

4 Shaping the Curve 4

5 Another Way of Looking at This 85% by 2016 and 90% by 2018 of this category 30% by end of 2016 & 50% by end of 2018 of this category Description Category 1: Fee for Service No Link to Quality Payments are based on volume of services and not linked to quality or efficiency Category 2: Fee for Service Link to Quality At least a portion of payments vary based on the quality or efficiency of healthcare delivery Category 3: Alternative Payment Models with Fee For Service Base Some payment is linked to the effective management of a population or an episode of care Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Category 4: Population-Based Payment Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., >1 year) Examples Limited in Medicare fee-forservice Majority of Medicare payments now are linked to quality Hospital value-based purchasing Physician Value-Based Modifier Readmissions/Hospital Acquired Condition Reduction Program Accountable care organizations Medical homes Bundled payments Eligible Pioneer accountable care organizations in years 3-5 Some Medicare Advantage plan payments to clinicians and organizations Some Medicare-Medicaid (duals) plan payments to clinicians and organizations Source: Rahul Rajkumar, MD, JD; Patrick H. Conway, MD, MSc; Marilyn Tavenner, RN, MHA CMS- Engaging Mulitple Payers in Payment Reform. JAMA. 2014;311(19(:

6 CMS Accelerates the Tipping Point for Everyone HHS goal of 30 percent traditional FFS Medicare payment through alternative payment models by the end of percent by the end of 2018 HHS Press Office % of payment tied to quality and value metrics (ex. Hospital Value Based Purchasing, Hospital Readmission Reduction Program) Traditional, Fee for Service Alternative Payment Models 6

7 Summary of Innovation Models Accountable Care Episode Based Payment Initiatives Primary Care Transformation Medicaid & CHIP Population To Accelerate Testing of New Models Speed Adoption of Best Practices ACOs BPCI Models 1-4 Advanced Primary Care Initiatives Reduce Avoidable Hospitalizations for NF residents State Innovation Models :Round 1 & 2 Beneficiary Engagement Model Advanced Payment ACO ACE Demonstration Comprehensive Primary Care Initiative Financial Alignment Incentive for Medicare & Medicaid Frontier Community Health Integration Community Based Care Transitions Comprehensive ESRD Care Initiative Oncology Care Model FQHC Advanced Primary Care Practice Strong Start for Mothers & Newborns Maryland All Payer Health Care Action and Learning Network ACO Investment Model Specialty Practitioner Payment Model Graduate Nurse Education Medicaid Innovation Accelerator Program Health Care Innovation Round 1&2 Innovation Advisors Program Next Generation ACO Model Comprehensive Care for Joint Replacement (CCJR) Independence at Home Medicaid Prevention of Chronic Diseases Health Plan Innovation Initiatives Million Hearts Pioneer ACO Multi Payer Advanced Primary Care Practice Medicaid Emergency Psychiatric Demonstration Medicare Care Choices Award Partnership for Patients Rural Community Hospital Demonstration Transforming Clinical Practice Medicare IVIG Demonstration 7

8 Alignment of Strategy and Metrics Questions to Ask How many metrics am I tracking? How many metrics are duplicated? Do they have the same numerator and denominator? Source? Are they aligned with our results and strategic goals? What contracts are coming up for renewal that should have new metrics or should be at risk (mgd care, medical directorships, PMAs, etc.) What are we focused on?

9 Anticipated Penetration of Value-Based Payment

10 Financial Impacts on Efforts to Date

11 Perceptions on Enabling Readiness

12 Reform Across the Continuum Advanced Payment Models: Commercial/Medicare/State Larger share of $ Transparency Ability to shop SNF Value Based Purchasing (VBP) Star Rating Alt Pmt Models- Hi End VBP/RRP/HAC VBPM/PQRS/MIPS Meaningful Use Comp Care For Total Joints Star Rating Roll out HHVBP Star Rating APMs- Low End

13 And Now We Present In Place Now: Nursing Facilities Hospital HCAHPS (Added Spring 2015) Dialysis Centers Medicare Advantage Plans Home Health Agencies (Started July 2015) Coming Soon: Overall Hospital Rating (expected 2016) 13

14 Are Our Stars Aligned? 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Distribution of Stars 5 Stars 4 Stars 3 Stars 2 Stars 1 Star US My State Performance period July 2013-June 2014 US Example State 5 Stars Stars Stars 2, Stars Star 5 1 Not Report 1,037 8 What is your dry run score? What are your non VBP/RRP/HAC areas for improvement?

15 Process for the Stars 15

16 Timeline of Performance Periods 16

17 Penalties and Pay for Performance Source: Healthcatalyst1 17

18 VBP Shifting of Domain Weights 1% 1.25% 1.5% 1.75% 2.0% 18

19 2018 Complete Picture [VALU E] [VALU E] [VALU E] [VALU E] 19

20 FY Metrics Domain HCAHPS Same composite since 2013 Outcomes/ Safety Mortality CLABSI PSI- 90 Mortality CLABSI PSI- 90 CAUTI SSI Mortality CLABSI PSI- 90 CAUTI SSI MRSA C Diff + CTM3 CLABSI PSI- 90 CAUTI SSI MRSA C Diff PC-01 Clinical Care AMI-7a AMI- 8a HF-1 PN-3b PN-6 SCIP-Inf-1 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-4 SCIP-Inf-9 SCIP-Card-2 SCIP-VTE-2 AMI-7a PN-6 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-9 SCIP-Card-2 SCIP-VTE-2 IMM-2 AMI-7a IMM-2 PC-01 Mortality Efficiency MSPB 20

21 FY 19 New Measure Added THA/TKA for 30 month performance period. January 1, 2015-June 30, 2017 Baseline of July 1, 2010-June 30, 2013 Risk standardized measure for complications after Total Hips and Knees surgeries for up to 90 days post surgery One of eight complications: AMI, pneumonia, sepsis, SSI, PE, death, mechanical complication or periprosthetic joint infection/wound infection. Each has a defined time frame Each is a Yes or No Risk adjusted for patient age, sex and comorbidities SOURCE: August 2014 Proposed Rules Federal Register 21

22 Readmission Reduction Program Multiple Periods at Once 3% penalty of Medicare Reimbursement at risk each program year Measured Populations 30 days from DISCHARGE AMI, HF, PN, COPD, THA & TKA August 2014: CABG Added to FY 2017 Performance Periods: 3 Year Rolling Program FY 15: July 1, 2010 June 30, % FY 16: July 1, 2011 June 30, % FY 17: July 1, 2012 June 30, % FY 18: July 1, 2013 June 30, % FY 19: July 1, 2014 June 30, %

23 How are Readmissions Measured? Scoring Index based at 1.0 Calculate Excess Readmission Ratio Facility Predicted Value Facility Expected Value Excess Readmission Ratio > 1 = BAD Excess Readmission Ratio < 1 = GOOD

24 Hospital Acquired Conditions 2 Domains of Hospital Acquired Conditions Identified If a hospital is in the BOTTOM QUARTILE (worst performing 25% in the country), it will be penalized a FULL 1% of Medicare Reimbursement Penalties began FY 15 (beginning October 1, 2014)

25 2016 Penalties are out The average penalty is.61% 25

26 Hospital Acquired Conditions: FY 2017 First Domain: PSIs 15% Second Domain: CDC 85% Pressure Ulcer Rate Foreign Object Left in Body Iatrogenic Pneumothorax Rate Postoperative Physiologic and Metabolic Derangement Rate Postoperative Pulmonary Embolism and Deep Vein Thrombosis Rate Accidental Puncture and Laceration Rate CLABSI CAUTI SSI Following Colon Surgery (FY 2016) SSI Following Abdominal Hysterectomy (FY 2016) Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia (FY 2017) Clostridium Difficile (FY 2017) 2016 HAC penalties are out and the threshold lowered to >6.75 for penalty

27 HAC Summary Potential addition of three metrics to PSI-90 composite through the NQF review process: Perioperative hemorrhage rate, Perioperative physiologic metabolic derangement rate and Post-operative operative respiratory failure rates. Would engage in additional rule-making if so Finalization of time periods for FY 2017: Domain 1= 24 month period ending 6/30/15 and Domain 2= CY 2014 and Weights are: Domain 1=15% and Domain 2= 85% Narrative on scoring if data is not reported and a waiver is not obtained-a score of 10 will be assigned Refinements in measurements for CLABSI and CAUTI to include Non-ICU locations starting in 2018 (CY 2015 and 2016 performance periods) Exception policy/waiver for hospitals that experience disasters or other extraordinary circumstances 27

28 Impact on DRG Payment Then apply Case Mix Index 28

29 Expansion of Pneumonia Expansion to include principal diagnosis of aspiration pneumonia, sepsis and respiratory failure with a secondary diagnosis of pneumonia present on admission Retrospective analysis on FY 2015 Mortality shows: Expansion would include an additional 686,605 patients bringing the total to 1,663,195 patients An additional 86 hospitals would meet the min case requirement 41% of the cohort would consist of these expanded definitions Retrospective analysis on 2015 Readmissions shows: An additional 670,491 patients for a total of 1,765,450 patients An additional 67 hospitals would meet the min case requirement 38% of the cohort would consist of these expanded definitions 29

30 Hospital IQR: Additions Hospital Survey on Patient Safety Culture (structural) Kidney/UTI clinical episode payment Cellulitis clinical episode payment Gastrointestinal Hemorrhage clinical episode payment Lumbar Spine Fusion/Re-Fusion clinical episode payment Hospital-Level, Risk Standardized Payment Associated with an Episode of Care for Primary Elective THA/TKA Excess Days in Acute Care after hospitalization for AMI Excess Days in Acute care after hospitalization for HF 30

31 Go Beyond the Acute Care Space 31

32 Physician Penalties Arrive The Penalty Phase Year/Program erx PQRS % % % % % % 2018*** 2019*** 2020*** 2021*** Meaningful Use Value Modifier -1.0%* -1.0% -2.0% -2.0% %** (each year) -4.0% * Penalties will be greater for unsuccessful e-prescribers ** Penalty amount could increase up to 5% depending on meaningful use success rates ***MIPS information is estimate only MIPS up to -4% up to -5% up to -7% up to -9% SOURCE: Medical Group Management Association (MGMA)

33 MACRA: Physician Payments Payment rates for will be.5% annually and then frozen Thereafter tiered.25% (MIPS participants) or.75% (APM participants). Creates MIPS: Merit-Based Incentive Payment System Starts 2019 & combines EHR incentive program, PQRS and VBPM Develops 4 categories of measures Quality, Resource Use, Clinical Improvement, & EHR Use Range of payment adjustments In 2019: -4% to +12% In 2027: -9% to +27% Program is budget neutral Allows providers in Alternative Payment Models (APMs) to opt out of MIPS and can be eligible to receive 5% lump sum bonus

34 SNF Value-Based Purchasing Good chance we are in the performance period now Requires 2 metrics: all cause readmissions and preventable readmissions Effective 10/1/18, with a 2% withhold Part of SGR fix in 2014 so not budget neutral: only 50%-70% to be returned to SNFs Same formula as hospital readmissions penalty 34

35 Medicare: Home Health Agencies 1. Announced in July the start of Star Ratings 2. Low spend providers in APMs 3. On July 6, 2015, CMS proposed the HHVBP Authorized by the ACA and implemented by CMMI as of 1/1/16 with the first payment year to be 1/1/18. Baseline year is CY15. Comments due by Sept. 4, 2015 Will be among all HHAs in 9 states: random selection Mass., Md., N.C., Fla., Wash., Ariz., Iowa, Neb., Tenn. Payments adjusted (performance year) Year 1 CY16 and 2 CY17: 5% Year 3 CY18: 6% Year 4 CY19 and 5 CY20: 8%

36 Road Ahead 36

37 Value-Based Care Programs: United $65B in Value Based Contracting by 2018YE 30% of commercial claims $70 $60 $50 $40 $30 $20 $10 $ Value-Based Payments Level of Financial Integration Fee-For- Service $43B in Value Based Contracting by 2015YE Achieving specific METRICS Primary Care Incentives Performance Based Contracts Performance- Based Programs Managing a specific CONDITION or SERVICE LINE Condition or Service-Line Programs Episodes Service Line Programs Managing entire POPULATION HEALTH Shared Savings Shared Risk Accountable Care Programs (ACOs) Degree of Care Provider Integration and Accountability Capitation + PBC 37

38 Value Based Contracting Value-based payment models align with a provider s risk readiness. Capitation + PBC Shared Risk Capitation Accountable Care Programs Level of Financial Risk Performance- Based Contracts Fee for Service Bundled/Episode Payments Shared Savings Centers of Excellence Performance-based Programs SOURCE: UHC Degree of Provider Integration 38

39 United Metrics & Results What metrics are used for nitedhealthcare s valueased initiatives? HEDIS Basic and HEDIS Extended Quality Measures Quality Defects Intermediate Outcomes HAC/HAI Optimal/Tier 1 Prescription Drugs Efficient Lab Use Risk adjusted ER and Admission Rates Readmission Rates/Avg Lengths of Stay Potentially Avoidable Hospitalizations Total Cost of Care Targets 39

40 Aetna Defines Value Based Care Value Based Care is emerging as a solution to address rising health care costs, clinical inefficiency and duplication of services, and to make it easier for people to get the care they need. In value-based models, doctors and hospitals are paid for helping keep people healthy and for improving the health of those who have chronic conditions in an evidence-based, cost-effective way. This is a departure from the traditional fee-for-service approach. With fee-for-service, doctors and hospitals are paid based on the number of health care services they deliver, such as tests and procedures. Payment generally has little to do with whether their patients health improves Accountable Care Organization 2. Patient Centered Medical Home 3. Pay 4 Performance (FFS Base) 4. Bundled Payments 40

41 Payer Common Themes Triple Aim High performing narrow networks Patient Liability Increasing Increasing transparency & cost focus Focus on quality measures Provider profiling Value based payment methodologies rolling out Government Payers Major Commercial Carries Employers Your Organization 41

42 Triple Aim Manage Population Health Ideal Care System Reduce Per Capita Cost Enhance the Experience of Care SOURCE: Advisory Board Webinar Don Berwick

43 Narrow Networks Narrow 32% Ultranarrow 38% Broad 30% Narrow and ultra-narrow network plans are prevalent in the public marketplace. Chart shows Distribution of Individual Exchange Narrow Networks by Network Breadth, 2014 (from the AHA Trendwatch Report, June 2014). 43

44 Patient Liability Increasing 44

45 CDHP Growth 45

46 ORIENTATION CALL ON SITE VERIFICATION GOALS Refine and finalize verification protocol Disseminate ideas to use the survey and results in quality improvement Collect feedback from hospitals on how Leapfrog can make the survey and the display of survey results more actionable so they can be used even more effectively in quality improvement Develop and test a business model to sustain the national roll-out of the on-site data verification program PRE-VISIT DOC REQUEST INTRO MEETING VERIFICATION PROTOCOL IMPROVEMENT STRATEGIES EXIT INTERVIEW FINDINGS REPORT

47 Failing Grades 47

48 Go Beyond Comfort Zones 48

49 HFMA Value Project Research hfma.org/valueproject 49

50 HFMA Is Reaching Out hfma.org/physician hfma.org/healthplan 50

51 Help Consumers Make Sense of the Numbers hfma.org/dollars 51

52 Equip Staff for Success in the Consumerism Era Agenda for live training on site for your patient access staff Slide deck that can be customized Sample financial policies Coaching guidelines hfma.org/dollars 52

53 Educate Consumers Describes how to request price estimates, step by step Clarifies what estimates may or may not include Explains in-network and out-of-network care Defines key terms hfma.org/consumerguide New: Provides information on assessing healthcare quality 53

54 Certification Reflects Strategic Importance of Finance Closely aligned with contemporary healthcare business environment Designed for financial professionals, clinical and nonclinical leaders, and payers Emphasizes the learning needed to shape the business environment 54

55 Stay Up to Date hfma.org Daily and weekly online news Social media Facebook LinkedIn Twitter HFMA Forums 55

56 In Conclusion 56

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