Housekeeping - AAMC€¦ · Housekeeping • Click ... Gainshare ICS and NPRA ... What is a CCJR...
Transcript of Housekeeping - AAMC€¦ · Housekeeping • Click ... Gainshare ICS and NPRA ... What is a CCJR...
Housekeeping
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Comprehensive Care for Joint Replacements (CCJR)
Proposed Rule Overview
Janis Orlowski, MD Coleen Kivlahan, MD Jessica Walradt, MSAAMC Health Care Affairs: Alternative Payment TeamAugust 6, 2015
Agenda
1. Why BPCI Matters: CCJR and AAMC’s Experience
2. CCJR Rule Overview3. Q&A4. Bundling 101 Boot Camp: Succeeding at CCJR
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BPCI OverviewIssue BPCI CCJR
Program duration 3 years (Ends by Sept. 30, 2018)
5 years (Jan. 1, 2016 - Dec. 31, 2020)
Baseline period FY 2009 - 2012Fixed
CY 2012 - 2014Rolling; rebased every other
year
Target price 100% hospital specific historical data
Blend of hospital-specific and regional historical data
Episode duration 90 days 90 days
Quality measures N/AMust meet threshold on 2
quality measures to qualify for savings
Gainsharing Gainshare ICS and NPRAGainshare ICS and NPRA
Can share downside risk with other providers
Beneficiary data Cannot opt out of having their data shared
Can opt out of having their data shared
Data sharing Data provided prior to go-liveMonthly updates
Hospitals must request dataData provided 60-days post-
go-liveQuarterly updates
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AAMC as Facilitator Convener
Learning Collaborative Advocacy Policy Analysis Data and Clinical Analyses Project Management
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AAMC’s BPCI Health Systems
Indiana
Michigan
California
Nevada
Oregon
Washington
Arizona
Utah
Idaho
Montana
Wyoming
Colorado
New Mexico
Nebraska
MaineVermont
New York
North Carolina
Georgia
South Carolina
Alabama
Mississippi Louisiana
Texas
Pennsylvania
Wisconsin
Minnesota North Dakota
Ohio
West Virginia
South Dakota
Arkansas
Missouri
Iowa
Illinois
Tennessee
Kentucky
DelawareNew Jersey
Connecticut
MassachusettsNew Hampshire
Virginia Maryland
Rhode Island
District of Columbia
Kansas
Oklahoma
Current Participants
July 2015
Florida
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AAMC BPCI Episodes
• Major joint replacement - lower extremity (19)• CHF (7)• CABG (5)• Cardiac valve (4) • Stroke (4)• Cervical spinal fusion (3) • COPD (3) • Spinal fusion (non-cervical) (3)• Double joint replacement - lower extremity (3)• Major bowel procedure (2)
Live as of October 1, 2015
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BPCI LEJR Experience: Risk and Opportunities
LEJR Savings range from 0.3% to 12% of target amount Opportunities: Over 80% of payments occur in the first 30 days, with 50% of total
payments in the index admission Major savings opportunity: post-acute care. Partnership with PAC
providers Evidence-based care process map for elective joint procedures Generate internal cost savings (ICS); gainsharing option engages
physician partnersChallenges: The efficient provider Hip fractures, non-elective joint replacement
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CCJR Participation
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Does this program apply to me?
COTH Non-COTH
Major TeachingNon-COTH
Minor TOTAL - ALL
TEACHINGTotal Hospitals 239 131 690 1,060 Total Hospitals in CCJR MSAs 94 61 243 398 % in CCJR MSAs 39% 47% 35% 38%Total in BPCI (April 2015) 45 18 96 159
Live with BPCI (Phase II) 20 8 27 55 Live with MJRLE 10 5 12 27 Phase I Only 25 10 69 104
Table 1. Hospitals in CCJR
75 out of 388, or 20% of, MSAs selected
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How did CMS select the 75 MSAs?
Start with 388 MSAs Eliminate MSAs based on LEJR volume and
BPCI LEJR market saturation Random stratification
1. MSA average wage-adjusted historic LEJR episode payments; and
2. MSA population size
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COTH Hospitals in CCJR MSAs
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Hospitals Excluded from CCJR
Hospitals not located in an MSA selected for CCJR
Maryland hospitals Hospitals not paid under IPPS (CAHs) Hospitals at-risk for lower extremity joint
replacements (LEJRs) in BPCI for the duration of their BPCI performance period
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CCJR Beneficiaries
CCJR Patient Eligibility Criteria: Medicare must be the primary payer Enrolled in Part A and B throughout the episode Does not have ESRD Not enrolled in any managed care plan Not covered under United Mine Workers of America health planBeneficiaries must be notified of the CCJR Model Unable to opt out of CCJR program – can change provider remains Can opt out of data sharingBeneficiary CCJR episode will be cancelled if: Beneficiary dies during anchor hospitalization Beneficiary initiates episode under BPCI Acute care readmission discharge is under DRG 469/470 (the first
episode is dropped and a new episode is initiated)
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CCJR Episode Definitions
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What is a CCJR bundle?
Anchor DRGs 469 and 470 Part A and B All cause readmissions with limited
exclusions Index hospitalization + 90 days post-
discharge Retrospective reconciliation
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Exclusions
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Payment Methodology
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Payment Methodology Overview
Retrospective payment methodology Providers bill and receive reimbursement via current FFS structure At completion of the performance year, actual aggregate episode
claim payments are compared against the episode target priceTwo-sided risk model Hospitals may receive a reconciliation payment if actual spending is
less than the target Certain quality measure thresholds must also be met
Hospitals are responsible for paying Medicare if actual spending is greater than the target
No downside risk in performance year 1Phased-in approach is used for downside risk inperformance year 2Full downside risk in performance years 3 through 5Must meet quality thresholds to be eligible for payment
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How will the target price be calculated?
3 year baseline period DRG-specific Exclude special Medicare payments (IME, DSH, P4P)
from target price and performance period Normalize for wage index
Trend to performance
period $Trend
factor = 1.01
Baseline average episode
payment = $28,000
Apply 2% discount
factor$28,280
Performance period target
price = $27,714
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CCJR Target Price
1 2 3 4 5
2/3
1/3
Savings
Losses N/A 1%
CY 2016 - 2018Baseline Period
1/3
2/3
0%
100%
CY 2012 - 2014 CY 2014 - 2016
2%
2%
Performance Year
Regional Data
Hospital-specific Data
Discount Factor
Target Price Components
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Target Prices: Regions
Source: http://www.eia.gov/consumption/commercial/censusmaps.cfm.
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How will reconciliation work?
All providers continue to be paid FFS Aggregate performance period FFS payments
retrospectively reconciled against target amount Savings impacted by quality scores
Target price Episode Count
Target Amount
Actual FFS Payment
Medicare Savings/Losses
DRG 469 $40,000 20 $800,000 $1,100,000 ($300,000)
DRG 470 $25,000 400 $10,000,000 $8,000,000 $2,000,000
Total 420 $10,800,000 $9,100,000 $1,700,000
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What risk protection does my hospital have in CCJR?
1 2 3 4 5
Discount Factor for Calculating Losses No downside risk 1%
Cap on Losses(% of Target Amount) No downside risk 10%
Performance Year
2%
20%
Total 10% Uncapped CappedCounty General
Hospital $30,000 $30 $900,000 $90,000 (110,000)$ (90,000)$
Target Amount Medicare Savings/LossesTarget
PriceEpisode Count
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High Episode Payment Ceiling
Each episode is capped at 2 standard deviations above mean
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High Episode Payment Ceiling
– Mean – 2 SD
Hospitals not responsible for payments above red line
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Quality Requirements
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What quality measures does my hospital need to meet?
• CCJR hospitals must meet quality performance thresholds to be eligible for reconciliation payments
• Three measures proposed (performance must meet threshold for all measures): o Total Knee Arthroplasty (TKA)/Total Hip Arthroplasty (THA) 30
day Readmissionso TKA/THA 90 day Complicationso Hospital Consumer Assessment of Healthcare Providers
(HCAHP) Survey• CMS plans to use existing measure rates posted on Hospital
Compare• Hospitals that voluntarily submit THA/TKA patient-reported
outcomes measure would be eligible for a lower discount percentage used to set the target priceo This measure has not yet been developedo CMS seeks feedback on other ways to reward voluntary
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Background on Proposed Quality Measures
Measure NQF #
Patient Population Data Collection
Period
Minimum Volume
Threshold
Additional Details
THA/TKA Complications
1550 FFS beneficiaries admitted to an acute care facility and having a qualified elective primary THA/TKA procedure
3 years Minimum of 25 cases
Measure does not capture partial hip arthroplasty procedures (included in DRGs 469 & 470)
THA/TKA Readmissions
1551 FFS beneficiaries admitted to an acute care facility and having a qualified elective primary THA/TKA procedure
3 years Minimum of 25 cases
Measure does not capture partial hip arthroplasty procedures (included in DRGs 469 & 470)
HCAHPS(patient experience)
0166 Hospital patients at least 18 years of age
1 year 100/surveys a year
HCAHPS scored using linear mean roll-up (same calculation as the HCAHPS star ratings)
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Overlap with Other Models
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Overlap With Other Payment Models
Accountable Care Organization (ACO)• Hospitals participating in CCJR may also participate in an ACO• Beneficiaries in both programs: Will attribute Medicare savings
accrued during CCJR time period to CCJRBundled Payment for Care Improvement (BPCI)• Hospitals live with LEJR in BPCI remain in BPCI for duration of
BPCI performance period• Should Phase II participants terminate from BPCI – they are
required to participate in CCJR, if within a designated MSA• BPCI Model 2/3 LEJR episodes will take precedence over CCJR
episodes
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BPCI LEJR Episode Takes Precedence Over CCJR Episode
Hospital A
CCJR
Physician in BPCI PGP B performs the
procedure.
Patient X receives joint replacement at Hospital A. PGP B claims
episode.
Critical Implication: <20 CCJR episodes/baseline Target price = 100% regional data
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Analyzing Episode Data
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How will I get episode data?
Must request data on or after start date (Jan. 1, 2016)
Will receive data within 60 days of request Summary claims data Beneficiary-level raw claims data
Updated quarterly Beneficiary opt-out
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Waivers and Gainsharing
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What waivers will be applied?
• Waive 3-day hospital stay for SNF payment requirement
• SNF rating must be > 3 stars• Maintain patient choice
SNF
• Waive “incident to” rule to allow post-discharge home visits
• Patient cannot be homebound• Maximum of 9 visits
Home Visits
• Waive geographic site and originating site requirements
• Cannot substitute for in-person HH services paid under Medicare HH benefit
Telehealth
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Can the hospital share savings (and risk) with other providers?
Can gainshare Medicare savings and internal cost savings with “CCJR collaborators” Cap on gainsharing payments made to physicians = 50% of PFS payments for services furnished to CCJR
beneficiaries Can share downside risk with CCJR collaborators Cap on aggregate “alignment payments” = 50% of hospital's repayment amount due to CMS Cap on individual alignment payment = 25% of hospital’s repayment amount due to CMS
CCJR Collaborators
SNFs, HHAs, LTCHs, IRFs, PGPs, physicians, non-physician practitioners, and outpatient
therapy providers who directly furnish care to CCJR beneficiaries during an episode and/or participate in CCJR care redesign activities.
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Questions
• Please use the Q&A panel located on the right hand side of your screen to submit your questions. Send to All Panelists.
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AAMC Support• Convener for 27 teaching hospitals in BPCI
with predominance of joint bundles• Oncology bundle support• CCJR support:
• CCJR summary and comment letter• Learning modules: “What is episode based payment?” • Partners in CCJR data support• Bundling and CCJR boot camp• TJR recent literature and best practice tools• How to Bundle manual
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AAMC Next Steps
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AAMC Next Steps in CCJR SupportBundling 101 Boot Camp: Succeeding at CCJR
• October 9, at the AAMC headquarters in Washington, DC
Attendees can expect:• Guest speakers with bundling expertise in AMCs• Practical steps and templates to use in
CCJR/bundled payments at your organization• Your organization’s TJR bundle data report• Group work on key challenges in TJR bundles• Flash drive with full day’s slides
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To Join Us…
• Formal registration will open in late August, but we have limited the size, and it is first come, first served, so let us know ASAP.
• Bring several colleagues in finance, operations and clinical areas
• 5 scholarships for residents available to advance engagement in new payment models
• One day boot camp, intense 8AM-5PM• If interested, reserve spots now at
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Appendix
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How does CCJR compare to BPCI?Issue BPCI CCJR
Program duration 3 years (Ends by Sept. 30, 2018)
5 years (Jan. 1, 2016 - Dec. 31, 2020)
Baseline period FY 2009 - 2012Fixed
CY 2012 - 2014Rolling; rebased every other
year
Target price 100% hospital-specific historical data
Blend of hospital-specific and regional historical data
Episode duration 90 days 90 days
Discount factor 2%
2% w/ adjustments for year 2 and voluntarily submitting patient-reported outcome
measures
Trend factor Retrospectively set national trend factor
Prospectively set hospital-specific/regional trend factor
Risk track(s) Choice of 3; responsible for 20% of costs above threshold
1 track; not responsible for costs above threshold
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BPCI vs. CCJRIssue BPCI CCJR
Reconciliation
Performance quarter retrospectively reconciled (4x) 6 months following the end of
the quarter.
Performance year retrospectively reconciled (2x)
1 quarter after end of year.
Cap on savings/lossesUpside only in CY 2014.
Savings/losses capped at 20% of target amount.
Upside only in year 1. 20% cap on savings. 10% cap on losses in year 2. 20% cap on
losses in years 3 - 5.
Quality measures N/AMust meet threshold on 2
quality measures to qualify for savings.
Gainsharing Gainshare ICS and NPRA. Gainshare ICS and NPRA.
Can share downside risk with other providers.
Beneficiary data Cannot opt out of having their data shared.
Can opt out of having their data shared.
Frequency of data sharing
Data provided prior to go-live. Monthly updates.
Data provided 60-days post-go-live. Quarterly updates.
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