Housekeeping. Questions

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1 Housekeeping To join us on audio, dial the phone number in the teleconference box and follow the prompts. Please dial in with your Attendee ID number. The Attendee ID number will connect your name in WebEx to your phone line. Click Communicate (located in the upper left hand corner) and then Audio Connection to access the information if you closed the teleconference box. Your line will be automatically muted. Questions Please use the Q&A panel located on the right hand side of your screen to submit your questions. Send to All Panelists.

2 Medicare Proposed Rule: Advancing Care Coordination Through Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model Jessica Walradt Scott Wetzel Matt Baker August 22, 2016

3 Agenda 1. Episode Payment Models (EPMs) 2. Cardiac Rehabilitation (CR) Incentive Payment Model 3. Questions

4 Episode Payment Models (EPMs): The Basics Start Date (mandatory) JULY 1, 2017 Timeframe 5 PERFORMANCE YEARS Savings CONTINGENT ON COST & QUALITY 3 EPISODES Surgical hip/femur fracture treatment (SHFFT) Acute myocardial infarction (AMI) Coronary artery bypass graft (CABG)

5 EPM Episodes Hospitalization + 90 days AMI CABG SHFFT MS-DRGs or PCI MS-DRGs w/ principal or secondary diagnosis of AMI MS-DRGs MS-DRGs

6 EPM Patient Eligibility Criteria: EPM Beneficiaries Medicare must be the primary payer Enrolled in Part A and B throughout the episode Does not have ESRD Medicare coverage Not enrolled in any managed care plan Not covered under United Mine Workers of America health plan Not aligned to Next Gen ACO or Comprehensive ESRD Care Initiative ACO in downside track Not be in any BPCI model episode Beneficiaries must be notified of the EPM model Unable to opt out of EPM program can change providers

7 EPM Participants: SHFFT 67 CJR MSAs

8 EPM Participants: AMI & CABG AMI and CABG EPMs to be implemented in the same randomly selected MSAs. MSAs excluded from selection based on: Volume of AMIs Volume of BPCI AMIs 294 eligible MSAs remain 98 will be randomly selected for participation

9 EPM Payment Methodology Standard Methodology Hospitalization + 90 days Average Episode Medicare Payments Across a 3 Year Baseline EPM Methodology Makes adjustments for: Chained anchor hospitalizations (transfers) CABG readmissions AMI diagnosis MS-DRG w/ MCC

10 EPM Payment Methodology AMI CABG

11 Regional Pricing

12 EPM Quality Overview Three separate EPM quality models o AMI, CABG, and Surgical hip/femur fracture treatment (SHFFT) Quality performance National Percentile o o o 30 th percentile minimum performance to receive points for each quality measure Points are awarded based on percentile Length of reporting period: AMI and CABG mortality, AMI excess days, and hip/knee complications 3 years HCAHPS 1 year Voluntary measures varies by performance year Performance + Improvement + Voluntary Points = Quality Composite Score

13 Quality Measure Composite Scoring AMI Quality Measures Weight Max Available Points Hospital AMI 30-day Mortality 50% 10 Excess Days in Acute Care After Hospitalization (EDAC) 20% 4 Voluntary Hybrid AMI Mortality 10% 2 if submitted successfully HCAHPS 20% 4 CABG Quality Measures Weight Max Available Points Hospital CABG 30-day Mortality 75% 15 HCAHPS 25% 5 SHFFT Quality Measures Weight Max Available Points Hip/Knee Complications 50% 10 HCAHPS 40% 8 THA/TKA Voluntary PRO 10% 2 if submitted successfully

14 Improvement Scoring Measure by measure basis Points awarded up to 10% of max performance points AMI/CABG Defined as improvement over participant s own point estimate from previous year SHFFT/CJR Defined as year over year improvement of two or more deciles

15 New Voluntary AMI Measure Hybrid measure combines standard claims based 30- day mortality with clinical data from EHR Submit five core data elements and six linking variables Age, heart rate, systolic BP, troponin, creatinine CCN, HIC#, DOB, sex, admission and discharge dates Heart rate and BP within 2 hours of admission; troponin within 24 hours Additional two points for successful submission

16 Deep Dive: SHFFT Quality Points Scale and Discount Rate Percentile THA/TKA Complications Points HCAHPS Points 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile 0 0 Not Enough Data to Report Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0%

17 Example: SHFFT Hospital Scoring Step 1 Convert Your Rate to Percentile Ranking THA/TKA Complications Rate HCAHPS Linear Mean Score Your Rate National Percentile 80-89th Percentile 60-69th Percentile Step 2 Convert Your Percentile Ranking to Points Percentile THA/TKA Complications Points HCAHPS Points 90-99th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile th Percentile 0 0 Not Enough Data to Report 7 5.6

18 Example: SHFFT Hospital Scoring, Cont. Step 3 Sum Total Points Total Points = THA/TKA Complications Points + HCAHPS Points + THA/TKA PRO Points Total Points = = Step 4 Assign to a Category Based on Total Points Composite Score Category Quality Category Eligible for Reconciliation Payment Reconciliation Payment Discount Percentage Repayment Amount Discount Percentage Year 1 Years 2 & 3 Years 4 & 5 > 15.0 Excellent Yes 1.5% N/A 0.5% 1.5% > 6.9 and <15.0 Good Yes 2.0% N/A 1.0% 2.0% >5.0 and <6.9 Acceptable Yes 3.0% N/A 2.0% 3.0% <5.0 Below Acceptable No 3.0% N/A 2.0% 3.0%

19 Projected COTH Quality Performance AMI Quality Rating % of COTH Members % of All Hospitals Quality Rating N = 130 N = 1,591 Below Acceptable 17% 10% Acceptable 11% 12% Good 54% 66% Excellent 18% 11% 83% of COTH CABG Quality Rating % of COTH Members % of All Hospitals Quality Rating N = 130 N = 1,591 Below Acceptable 5% 5% Acceptable 7% 6% Good 68% 83% Excellent 20% 5% 95% of COTH SHFFT Quality Rating % of COTH Members % of All Hospitals Quality Rating N = 74 N = 779 Below Acceptable 15% 8% Acceptable 11% 13% Good 66% 66% Excellent 8% 13% 85% of COTH

20 Questions?

21 Risk Mitigation Ceiling on Outlier Episode Payments = 2 standard deviations above regional mean (DRG-specific) Payments excluded from reconciliation calculations

22 Risk Mitigation: Cap on Total Losses Example

23 EPM Financial Arrangements CMS proposed to allow both gainsharing and sharing of downside risk in EPMs. Both of these amounts are subject to a cap. Gainsharing Payment EPM Participant Hospital EPM Collaborator Alignment Payment

24 EPM Financial Arrangements Pg. 473 CMS-5519-P

25 Waivers SNF Home Visits Telehealth CR/ICR Services Waive 3-day hospital stay for SNF payment requirement for starting in PY2 SNF rating must be > 3 stars AMI episodes only Waive incident to rule to allow post-discharge home visits Patient cannot be homebound Maximum visits: AMI = 13; CABG/SHFFT = 9 Waive geographic site and originating site requirements Cannot substitute for in-person HH services paid under Medicare HH benefit Waive the definition of physician to allow certain nonphysician practitioners to perform the functions of the supervisory physician, prescribe exercise, and establish, review, and sign an individualized treatment plan for a provider or supplier of CR/ICR services

26 Must request data Data Sharing 3-year baseline period and performance period data Beneficiary-level claims data Hospital-specific summary data Aggregate regional data Updated quarterly

27 Overlap with Other Models MSSP ACO BPCI Hospital Awardee EPM Hospital Next Gen ACO

28 Overlap with Other Models Excluded (Beneficiary cannot trigger an EPM episode) Next Gen ACO ESCO (downside risk track) BPCI Savings Attributed to EPM MSSP ACO (all tracks) Excludes PBPM Payments from EPM Episodes OCM Medicare Care Choices Model

29 Advanced APMs Track 1 Required to use CEHRT Meets Advanced APM requirements Track 2 Would not meet Advanced APM requirements

30 Questions?

31 CR Incentive Program

32 CR Incentive Participants 45 MSAs (FFS-CR MSAs) 45 MSAs (EPM-CR MSAs)

33 CR/ICR Services

34 CR Incentive Payments First 11 services = $25/service $175/service thereafter, no limit

35 Questions?

36 Next Steps Comments Due: OCTOBER 3, 3016 Seek input from leadership and staff on key provisions CMS webinar on August 31 st at noon EST Send feedback and questions to

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