Home Health Value Based Purchasing 2016 and Beyond

Transcription

1 Home Health Value Based Purchasing 2016 and Beyond Chris Attaya, VP Business Intelligence, SHP Rey Spadoni, President, Partners HealthCare at Home Sixth Annual New England Home Care & Hospice Conference and Trade Show May 17, 2016

2 About the Partners HealthCare System $11B health care system founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital, Partners HealthCare System (PHS) includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. Per the US News Ranking: Massachusetts General Hospital #1 Brigham & Woman s Hospital #6 Spaulding Rehabilitation Hospital #6 Rehab Massachusetts Eye & Ear #1 ENT McLean Hospital #4 Psych A teaching affiliate of Harvard Medical School; national leader in biomedical research. Partners is the largest private employer in Massachusetts, with approximately 60,000 employees, including physicians, nurses, scientists, and caregivers. 2

3 About Partners HealthCare at Home $95m home health agency established in 2000 with the merger of 27 VNAs Certified home health care services, per year ADC 3,700 Admissions 27,000 Visits 470,000 Private care services, per year ADC 1,100 Hours 450,000 Special programs Telemonitoring Mobile observation unit Wound care Infusion Pediatrics Enterprise technology platform: Epic (May 2015) 3

4 Learning Objectives Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP 4

5 Learning Objectives Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP 5

6 HHVBP Components CMS HHVBP Goals OASIS, Claims and HHCAHPS Measures New Measures Piloted States Selection Criteria Measure Points Scoring Larger vs Small volume HHA Cohorts Important Updates from CMS Q & A s HHVBP Connect Site 6

7 CMS HHVP Goals CMS is proposing the use of quarterly performance reports, annual payment adjustment reports, and annual publicly-available performance reports as a means of developing greater transparency of Medicare data on quality and aligning the competitive forces within the market to deliver care based on value over volume 7

8 Measures by NQF Domain DOMAINS 1) Patient and Caregiver centered experience 2) Clinical Quality of Care 3) Communication & Care Coordination 4) Population Health 5) Efficiency and cost reduction 6) Safety 8

9 New Measures Each of these new measures will need to be reported by HHAs through a Web Portal starting with Q3 data Measure Measure Type Notes Influenza Vaccination Coverage for Home Health Care Personnel Herpes zoster (Shingles) vaccination: Has the patient ever received the shingles vaccination? Process Process % HHA personnel received or documented not received medical condition, received elsewhere, declined, unknown. Need to have worked 1 day Oct 1 to March 31st # of Medicare beneficiaries over 60 that ever received shingles vaccine Advanced Care Plan Process Patients over 18 with plan or discussed with patient (no surrogate or plan made) 9

10 New Measures for the Portal Review and understand the numerator and denominator values before starting data collection Do not wait to start collecting even though they are not due to be submitted until October 7 th, 2016 Centralize the collection and reporting within your organization Conduct your own dry run to ensure you have the data available and ready to enter into the Portal Plan to enter a least a week before they are due to make sure there are no glitches! 10

11 Example of Herpes Zoster 13 questions need to be collected in this example 11

12 Domains into Classifications Classification I Clinical Quality of Care Domains into Classifications Classification II Outcome & Efficiency Classification III Person & Caregiver-Centered Experience Classification IV New Measures 12

13 Piloted State Selection Criteria Randomly Selected States Started with nine geographically-defined groupings of five or six states based on geographic, sample size and patient characteristics The 9 pilot states are: Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee 13

14 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 14

15 Measure Points Scoring (cont.) Measure Points Scoring (cont.) 15

16 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 16

17 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 17

18 Measure Points Scoring (cont.) Measure Points Scoring (cont.) 18

19 Large vs. Small Agency Cohorts Agencies reporting will be broken down in 2 Cohorts Large: HHCAHPS Participant, and Small (Exempt from HHCAHPS due to <60 eligible patients in the calendar year) Intention to is group like agencies for performance reporting 19

20 Performance Reporting CMS quarterly will provide each agency with their scores The first report will be available in July 2016 for the 2016 Q1 data Agencies will have the opportunity to contest their scores within 30 days of receiving Agencies will also have a chance to review their TPS and payment adjustments August 1 st first notification 30 days to request recalculation Final report no later than November 1, 2017 Annual quality performance reports will be made publically available 20

21 CMS Q&A s Dec 2015 Notable Answers: Information about the measures utilized in the first year of the HHVBP Model, including the measure specifications for the coordination of care and prior functioning measures will be presented during a webinar tentatively scheduled for January OASIS-based measures are calculated using assessments from the OASIS assessments from Medicare FFS, Medicare Advantage, Medicaid FFS, and Medicaid Managed care. All Medicare certified agencies in the 9 states are required to participate, even those with as few as 10 cases/year. CMS is compiling aggregate benchmark and achievement thresholds based on 2013 and 2014 data. Only the aggregate level Benchmarks and Achievement thresholds (by state and by cohort size) will be calculated using the 2013 and 2014 data. 21 Source: Value-Based-Purchasing-Model/faq.html

22 HHVBP Connect Site HHVBP Connect: An interactive platform to learn more about the Model and collaborate with other HHAs Find the latest updates for the HHVBP Model Download valuable resources to help you succeed in HHVBP View upcoming HHVBP events and key Model milestones Sole source for event registration Share best practices and chat with your colleagues in the nine Model states HHVBP Secure Portal Where HHAs will submit data on new measures Where HHAs will retrieve quarterly and annual reports 22

23 HHVBP Connect Site Landing Page HHVBP Connect Site Landing Page 23

24 HHVBP Baseline and Performance Periods HHVBP Base Line and Performance Periods 24

25 Hospital Value Based Purchasing (HVBP) What can we learn about this implementation? Has changed over time The number of measures and domains have changed in each of the last 3 years since it s inception, including Domain weighting HCAHPS also includes points for consistency if better than the 50 th percentile in each of the Patient Experience dimensions The Bonus or Penalty is netted against the withholds in each year limiting the impacts on cash flow Unlike the Home Health Proposal, the Base year for Hospitals change every year by one year 25

26 Hospital Value Based Purchasing (HVBP) (cont.) Measures and Domains 26

27 Learning Objectives Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP 27

28 Total Performance Scoring 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 28

29 Total Performance Scoring (TPS) (cont.) TPS Example (HHA 1) Total Performance Scoring (TPS) (cont.) 29

30 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 =

31 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 31

32 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 32

33 CMS HHVBP Impact Reporting Distribution of the Payment Adjustments in the different model years CMS HHVBP Impact Reporting 33

34 CMS HHVBP Impact Reporting (cont.) Example of HHA Large Cohort Payment Adjustments CMS HHVBP Impact Reporting (cont.) 34

35 LEF Distribution Examples LEF Distribution Examples 35

36 LEF Distribution Examples (cont.) LEF Distribution Examples (cont.) 36

37 LEF Distribution Examples (cont.) LEF Distribution Examples (cont.) 37

38 LEF Distribution Examples (cont.) 38

39 LEF Distribution Examples (cont.) 39

40 Create Financial Baseline Meet with Operations and Quality to determine first pass at what if criteria for change on each measure. Using TPS computed, work through calculations in the Linear Exchange function to determine financial impact/risk for this first pass of assumptions. Create variation examples within each domain and across domains taking into consideration clinical team variation in scoring, resources needs ~ what s a heavy lift and areas needing immediate or critical focus for the organization. Develop a table of each iteration recording results on assumptions on each measure, TPS and related financial impact. Share results with Operations and Quality team to help focus initiatives. 40

41 The Foundation of Analysis is Accurate Data Develop or obtain a tool to organize data for easy reference to domain, measure, data sources etc. Measure Threshold Benchmark What if Achv. Imprv. Pts. Pts. Final Pts Verify data from all sources Insert proxy data for any missing variables Achievement, Threshold and Benchmark will change as all agencies innovate for improvement 41

42 Financial Risk Estimates - PHH Estimated TPS Distribution for Agency Cohort * * Agency Medicare Budget Payment Adjustment Distribution 42 Estimated Payment Adjustment if TPS = 35 If TPS = 55 If TPS = 75 CY2016 $63,432,660 3% ($342,436) $190,298 $922,945 CY2017 $66,604,294 5% ($589,448) $329,691 $1,605,163 CY2018 $69,934,508 6% ($755,293) $419,607 $2,035,094 *actual adjustment % will change with cohort distribution and annual % distribution

43 Learning Objectives Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP 43

44 Government payers payment reform and quality timeline 10/1/2007: Pay for Performance begins 3/2010: Passage of Affordable Care Act Increasing Velocity of Change 1/1/2011: Center for Medicare & Medicaid Innovation (CMMI) established 1/1/2012: Pioneer ACO and Medicare Shared Savings Programs begin; ESRD Quality Incentive Program begins; e-prescribing mandatory for MD s 1.0% VBP withhold 1.0% max readmission penalty 10/1/2012: Value Based Purchasing (VBP) begins; Readmissions Penalty begins 1.25% VBP withhold 2.0% max readmission penalty 1.5% VBP withhold Addition of VBP Efficiency Domain 3.0% max readmission penalty onwards Physician Value Based Payment Modifier in effect for some MDs 10/1/2011: Readmissions Penalty begins Health Policy Commission material changes/market reviews 10/1/2013: Inpatient Psych Quality Reporting Program begins; Quality reporting for LTCHs and Inpatient Rehab Facilities begins Phase I of Bundled Payments for Care Improvement Program begins July 2014: IOM Committee on GME Reform Report is published 10/1/2014: Hospital Acquired Conditions penalty begins 1/1/2015: Physician Value-Based Payment Modifier 3/2015: Next Generation ACO announced SGR repeal ties a greater share of physician payment to quality Federal FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 [Future] Increased oversight of insurance market Cost Trend Hearings TME / Relative Price Reporting 1.75% VBP 2.0% VBP withhold Medicaid F2F HHVBP IMPACT Act Discharge COP Care initiative for dual Medicare/Medicaid beneficiaries 1/1/2013: Mandate to increase penetration of alternate payments from 25% to 80% by 1/1/15 withhold onwards Physician Value Based Payment Modifier in effect for all MDs 10/1/2013: Primary Care Payment Reform Initiative (PCPRI) MassHealth ACO Request for Information Insurer calculation of enrollee out of pocket liability by provider State FY08 FY09 FY10 FY11 FY12 FY13 44 FY14 FY15 FY16 FY17 [Future] PCPRI: PMPM payment for PCP Services Payment adjusted for quality Shared Savings/Risk (optional) on total spend Goal of 50% of Medicare payments in alternative payment and/or population based payment by 2018 Site Neutral Payments (IP/OP; LTCH/IRF/SNF) Short Stay payment reform Home Health Quality Improvement Program Expansion of Shared Savings & Bundled Payment Programs Expansion of quality measure set for VBP, readmissions, HAC, inpatient psych, ESRD, condition specific Medicare Spending Per Beneficiary, etc Cap TME growth Medicaid inpatient psych bundled payment proposal MassHealth announced stakeholder sessions aimed at improvements / new payment models; Downing Bill introduced Continued expansion of quality measure set for P4P

45 Value-Based What? Our first reaction Please make it go away! 45

46 Value-Based What? Our second reaction What me worry? 46

47 Value-Based What? Our third reaction 47

48 Goal is to synergize efforts while not muddling priorities and overcomplicating (e.g., case conferencing) 48

49 Action step sequence for PHH 49

50 Take Stock of your Scores and PI Programs Where are our agency s scores in relation to our state averages? Have we chosen the right comparison group? How have our quality and satisfaction scores improved over time? How does our Quality of Patient Care Star Rating compare to our state s star ratings? Where do we have the best opportunity to improve our scores: Process measures, Outcomes, HHCAHPs? Begin to drill down 50

51 How does Massachusetts compare to the Nation? Outcomes Measures State Nation 51

52 VBP Measures National vs. Massachusetts VBP Measures National vs. Massachusetts Source: HHC Scores Posted October

53 Partners HealthCare at Home Outcomes 5 Star Focus Areas Improvement in Pain Drug Education Flu Vaccine 60 Day Hospitalization 53

54 Partners HealthCare at Home HHCAHPs 5 Star 54

55 High Level Strategies It takes a village Improvement is everyone s job Focus and data must be at the Team and Clinician Level Choose the highest bar (State, National, SHP) as your benchmark For Dashboards - Use stoplight color coding with goal to Get the Red Out simplify reporting for impact Use Innovative Visuals like Tornado charts to drive home points like Rate of Improvement 55

56 Different Benchmarks for HHVBP and 5 STAR Different benchmarks yield Different pictures Compared to CMS National Compared to SHP State 56

57 VBP/5-Star Rate of Improvement Tornado Chart shows Rate of Improvement Ambulation Bed Transfer Bathing Pain Interfering w/ Activity Dyspnea Timely Initiation of Care Drug Education All meds in Short Tem EOC Management of Oral Meds Flu Vaccine Received - Current Season PPV Received - Ever Composite 1: Care of Patients Composite 2: Comm Between Providers & Patients Composite 3: Specific Care Issues Universal 1: Gave the HHA a score of 9 or 10 Universal 2: Would recommend the HHA PHH Rate State CMS Rate State SHP Rate

58 Education Strategies Clinical Managers, Quality, OASIS review and education staff all work together as a team Identify team/clinician specific opportunities for improvement Education at the team and clinician level Monitor progress and provide ongoing real time feedback Re-educate as needed but not in perpetuity Performance management is critical Focus on entire spectrum from OASIS competency through to clinical practice offer Competency Days Celebrate Improvements big and small 58

59 Education Strategies Using Data Outcomes Improvement vs Stabilization at Team and Clinician level Room for improvement on one specific measure Room for improvement for one specific patient Patient level detail 59

60 Education Strategies Using Data HH Provider handled specific issues correctly HHCAHPs at Agency, Overall and Specific Question level At SOC, did someone from agency talk with you about how to set up home? About Rx and OTC? 60

61 Educational Approach OASIS Accuracy Skits/Videos demonstrating the right and wrong way to assess Home Care Institute Room by Room Fazzi OASIS Walk Improvement Concepts Improvement vs Stabilization Use of Dashboards and Tornado Graphs Care Planning and Goals Interprofessional Collaboration Regular Case Conferencing Real Time Feedback from OASIS Reviewers Focus Topics 61

62 Evaluating Adding full-time resource to bridge between Quality/Education and Clinical Operations - based in Ops Help convert analysis, findings, strategies to action Help de-clutter multitude of priorities Support accountability orientation ROI is compelling Role tension 62

63 Re-assess as you go. Run quarterly sensitivity analysis and develop quarterly review sessions. As all HHA s innovate to improve, the calculations remain dynamic. Check with corporate office concerning accounting ~ many hospital systems have experience and have developed standards for i.e. reserves for VBP and the associated timing. This could potentially play a role in future budget processes. 63

64 Lessons learned Synergize efforts where possible (case conference should be targeted; multiple birds one rock) Culture change Influence/change clinician behavior; performance management Management discipline Convert analysis to action Clinical managers need specific strategies to work with individual staff Reduce variation to allow for broader interventions Set it and forget it NOT. Quarterly assessment meetings (iterative and learning process) Properly reserve so no P&L surprises Work with IT vendor (on new measures); start early as not all are preparing 64

65 Questions & Answers 65

66 Contact Information Chris Attaya VP of Business Intelligence Strategic Healthcare Programs (SHP) Main: Cell: Rey Spadoni President Partners HealthCare at Home Direct: