Home Health Value-Based Purchasing. April 6, :00-3:45 pm

Transcription

1 Home Health Value-Based Purchasing April 6, :00-3:45 pm

2 Learning Objectives Understand the changing health care landscape, including various models of value-based purchasing Learn how the HHVBP demo program is shaping care delivery and what it means for your agency Identify risks and opportunities for your agency Share best practices, resources, and member experiences

3 Agenda Welcome & Introductions Health System Transformation and Innovation HH VBP Demonstration Program Overview Implementing VBP: Performance Modeling and Readiness Readiness Exercise Putting It In Practice: Member Experiences Tools and Resources

4 Health System Transformation

5 Key Assumptions Health system reorienting towards value Value-based purchasing (VBP) can improve coordination and health outcomes Payers (including Medicare) and providers are working together on innovative delivery system reforms Home Health can play a critical role in many care delivery models

6 Transition away from FFS In January 2015, HHS announced: Aggressive shift from volume-based to valuebased payment for Medicare Goal: 85% of Medicare FFS payments tied to performance by end of 2016 Goal: Transition at least 30% of all FFS payments to alternative payments (inc shared savings and bundles) by end of 2016.

7 Common alternative payment models Pay for Performance (P4P) Care Coordination Shared Savings Bundled Payments Capitation Pay-for- Performance Care Coordination Shared Savings Bundled Payments Capitation

8 Pay for Performance Description A portion of a provider's payment is based on its performance on established metrics of quality, health outcomes, and efficiency Maintains existing FFS payment structure Payers and providers must identify performance metrics and providers must develop systems and capacity to collect and track data Delivery System Alignment All providers and delivery system models

9 Care Coordination Description Payers generally reimburse care coordination services on a PMPM fee Payment varies by service provided; risk level of patient Providers deliver all care coordination services in the month Delivery System Alignment Primary Care Medical Homes; Health Homes; ACOs

10 Shared Savings Description Payers and Providers agree to a spending target for a set of services; Payer monitors cost of services against spending target If costs are less than targets, providers may be eligible to share in savings generated If cost of care is more than target, providers may be required to reimburse payer Quality/health outcome standards Delivery System Alignment ACOs; Retroactive Bundled Payment Models; PCMH

11 Bundled/Episodic Payment Description Payers pay a single price for a set of services for a given condition Provider is responsible for paying the other providers who treated the patient during the episode of care Providers only responsible or covering the costs of services associated with that one condition Delivery System Alignment Prospective Bundled Payment models

12 Capitation Description Payers pay a single PMPM for a set of services for a designated population Delivery System Alignment MCOs; Primary Care Providers

13 PAC-Specific Reforms ACO Models Pioneer ACO: Certified for expansion Next Generation ACO Model Bundled Payment Models Comprehensive Care for Joint Replacement (CCJR) Value-based Purchasing HH Value-based purchasing demo SNF Value-based purchasing program

14 Interest in Additional Reforms MedPAC s Unified Payment System for PAC (proposed) SFC Chronic Care Working Group (pending) Implementation of IMPACT Act

15 IMPACT Act GOALS: Comparison across post-acute/long-term care Improved quality care and outcomes Improved communication and interoperability Recommendations on payment reform Methods: Selectively standardize: assessment data, data for QMs, and data on resource use Replace some elements of current assessments (OASIS, MDS, IRF-PAI, LTCH) Assess at admission and discharge

16 Tool Kit Overview Tool Kit Overview Alternative Delivery and Payment Models Sample Performance Metrics Risk Management Comprehensive Care for Joint Replacement HH Compare Star Ratings

17 Home Health Value Based Purchasing Demo

18 HHVBP: Background CMS published the final rule for HHVBP Model in November The model: Incentivizes Medicare HHAs to provide higher quality and more efficient care; Tests whether a payment incentive of up to 8% significantly improves provider performance; Test the use of new quality measures in the home health setting; Updates the current public reporting process.

19 HHVBP: Background The model includes ALL Medicare-certified HHAs in nine states: Arizona Florida Iowa Maryland Massachusetts Nebraska North Carolina Tennessee Washington

20 HHVBP: Background Demo began January 1, 2016 and runs through CY 2022 Payment adjustments tied to quality performance HHAs are scored based on quality of care delivered to all patients receiving services compared to: Performance of their peers within their state, defined by the same size cohort, and Their own past performance on the measures.

21 HHVBP: Background Data Collection Quality Improvement Activities Data Submission/Reporting Total Performance Score Annual Payment Adjustment Quarterly Performance Reports Quality Improvement Activities

22 Baseline and Performance Year Calendar year 2015 will serve as the baseline year Not readjusted during the demo Performance Years of the model are 2016, 2017, 2017, 2019, 2020 Individual HHAs will be measured against a cohort of similar agencies in the state HHAs will be measured against a benchmark performance measure standard

23 Quality Measures 6 process measures from existing OASIS data collection 8 outcome measures from existing OASIS data and 2 outcome measures from claims data 5 HHCAHPS consumer satisfaction measures 3 new measures Points achieved by reporting data Submitted through the HHVBP portal

24 Cohorts Cohort is the grouping in which individual HHAs are competing Cohorts defined by states and, in some states by HHA size 60+ beneficiaries in a calendar year 59 or fewer beneficiaries in a calendar year

25 Benchmark Benchmark is the performance measurement goal for HHAs Benchmark is calculated as the mean of the best 10% of all HHAs within a cohort in the baseline year

26 Achievement and Improvement Points HHA receive Achievement Points for each measure for its own performance against the benchmark HHAs receive Improvement Points for a measure based on its change in performance relative to baseline year Points range from 0-10 Total Performance Score takes the HIGHER of Achievement or Improvement points for EACH measure

27 Total Performance Score (TPS) TPS summarizes an individual HHAs performance on quality measures relative to other HHAs in its cohort AND its own baseline year. TPS include if HHAs report data on New Measures TPS used to determine payment adjustment TPS calculated by summing the points for each measure and adjusting for number of measures available

28 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

29 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

30 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

31 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

32 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

33 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

34 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performanc e Period April 2016 Achievemen t Thresholds & Benchmarks Available Oct 2016 Quarterly Performanc e report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performanc e Year 1 Begins July 2016: First Quarterly Performanc e Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performanc e Goes Into Effect (Up to 3%)

35 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

36 Total Performance Score (TPS) Jan-Dec 2015: Baseline Performance Period April 2016 Achievement Thresholds & Benchmarks Available Oct 2016 Quarterly Performance report and first New Measure submission Nov 2017: Final Payment Adjustment Report Available Jan 1, 2016 Performance Year 1 Begins July 2016: First Quarterly Performance Report Available Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

37 CMS Secure Portal Portal provides access to: Submission of new measures Performance results All communications/webinars Website resources ALL Medicare-certified HHAs must provide a primary contact AND register for portal

38 Value Based Purchasing Overview of Performance Model and Calculations Chris Attaya VP of Business Intelligence

39 Measure Points Scoring Each Measure will have points scored based on the higher of an achievement score or improvement score Using the Base Year Period two calculations are set Threshold Value 50 th percentile (Median) Benchmark Mean of the top decile (~95 percentile) Base Year (Calendar Year 2015) will not change Performance Years Each measure needs 20 or more episodes to be included in the total performance scores New Measures will be scored based on self reporting data only 39

40 Measure Points Scoring (cont.) 40

41 Measure Points Scoring (cont.) Achievement Points By Pilot State Awarded by comparing an individual home health agency s rates during the performance period with all home health agency s rates from the baseline period Rate equal to or better than the benchmark: 10 points Rate less than the achievement threshold: 0 points Rate equal to or better than the achievement threshold and worse than the benchmark: 0 10 points 41

42 Measure Points Scoring (cont.) Improvement Points By Agency Awarded by comparing an individual home health agency s (HHA s) rates during the performance period with that same individual HHA s rates from the baseline period. Rate equal to or better than the benchmark: 10 points Rate worse than the agency s base year rate: 0 points Rate equal to or better than the agency s base year rate and worse than the benchmark: 0 10 points 42

43 Measure Points Scoring (cont.) 43

44 Achievement Calculation Achievement Points CMS Webinar Example 44

45 Improvement Calculation Improvement Points CMS Webinar Example 45

46 Total Performance Scoring (TPS) CMS proposing that TPS and payment adjustments would be calculated based on an HHA s CCN and therefore, based only on services provided in the selected states 21 OASIS/HHCAHPS/Claims based measures will be used in the TPS unless the an agency does not have 20 or more episodes per measure (Accounts for 90% of the score) Three New Measures will account for the 10% of the score If an HHA does not meet this threshold to generate scores on five or more of the Clinical Quality of Care, Outcome and Efficiency, and Person and Caregiver-Centered Experience measures, no payment adjustment will be made 46

47 Total Performance Scoring (TPS) (cont.) TPS Example (HHA 1) 47

48 Total Performance Scoring (TPS) (cont.) Scores on 16 available OASIS/HHCAHPS measures = 88 Points HHA 1 s total possible points would be calculated by multiplying the total number of measures for which the HHA reported on least 20 (twenty) episodes by the maximum number of points for those measures ten (10), yielding a total of 160 possible points 88 points divided by the total 160 = points X 90 = 49.5 New Measures all three entered equals 30 points out of a maximum of 30 = 1.0 X 10 points = 10 points Total Points =

49 New Measure Scoring For each New Measure, HHAs will receive 10 points if they report the New Measure or 0 points if they do not report the measure. New Measures will account for 10% of the TPS regardless of the number of measures applied to an HHA in the other 3 classifications. Examples: 3 measures entered would be awarded 10 points 2 of the 3 measures would be awarded points Points will be prorated if new measures entered for one quarter are different than other quarters 49

50 Net Reimbursement Impacts Each agency s value-based incentive payment amount for a fiscal year will depend on: Range and distribution of agency total performance scores Amount of agency's base operating HHRG payment amount The value-based incentive payment amount for each agency will be applied as an adjustment to the base operating HHRG payment amount for each episode 50

51 Value-Based Purchasing (HHVBP) CMS will use a linear exchange function (LEF) to distribute the available amount of value-based incentive payments to agencies, based on agency s total performance scores on the HHVBP measures 51

52 CMS HHVBP Impact Reporting Distribution of the Payment Adjustments in the different model years CMS HHVBP Impact Reporting 52

53 CMS HHVBP Impact Reporting (cont.) Example of HHA Large Cohort Payment Adjustments CMS HHVBP Impact Reporting (cont.) 53

54 LEF Distribution Examples LEF Distribution Examples 54

55 LEF Distribution Examples (cont.) LEF Distribution Examples (cont.) 55

56 LEF Distribution Examples (cont.) LEF Distribution Examples (cont.) 56

57 LEF Distribution Examples (cont.) 57

58 LEF Distribution Examples (cont.) 58

59 Trended SHP HHC VBP scores in NC 59

60 Trended SHP HHC VBP scores in NC (Cont.) 60

61 Trended SHP HHC VBP scores in NC (Cont.) 61

62 The Foundation of Analysis is Accurate Data Develop or obtain a tool to organize data for easy reference to domain, measure, data sources etc. Verify data from all sources Insert proxy data for any missing variables Make reasonable assumptions on outcome trends Determine your risk tolerance Create a model to test your assumptions 62

63 What-if Sensitivity Analysis 63

64 Greatest Opportunity to Improve Example: Improvement in Dyspnea Model 1 Run Rate from CY 2015 Model 2 Lowest Performers reach Agency median Model 3 Stretch Goal with strong Training investment 64

65 Greatest Opportunity to Improve (Cont.) Considerations What-if all clinicians improve by X% point? Or elevate lowest 50 th percentile to median What are the easier measures to change? PM s Outcomes HHCAHPS Is there best practices already in my agency At what cost Return on Investment (ROI)? $1,000,000 Medicare revenue = $30,000 risk first year What is the opportunity cost of not doing something? 65

66 Greatest Opportunity to Improve (Cont.) 66

67 Keys to Watch Out For Quarter 1 is closed Your agencies CY 2016 performance will include a 25% share of those scores Set goals for each quarter hitting your target by year-end is good but remember it is a year-to-date calculation Be careful of analysis paralysis Pick the top 2 4 measures to focus on not on all 21 Improvement in Star Rating measures are a Two-fer 67

68 Questions & Answers 68