Opportunities for Orthopedic Specialists in BPCI Advanced

Transcription

1 Opportunities for Orthopedic Specialists in BPCI Advanced January 13 th, 2018

2 Introduction CMS announced the voluntary Bundled Payment for Care Improvement (BPCI) Advanced program on Tuesday, Jan 9 th Goals of today s presentation: Introduce Archway Health Illustrate the benefits for providers of bundled payments Provide an overview of the details of the BPCI-A program Explain how to get started Address questions from the group 2

3 01 ARCHWAY HEALTH 3

4 Archway Overview Company Background 100% focused on bundled payments Built comprehensive, one-stop-shop bundled payment platform Founded in 2014 with offices in Boston and NY Backed by athenahealth & Coverys Experienced Team Team has been active in BPCI since its inception in 2011 Active in all of CMS bundled payment programs BPCI, CJR, OCM, EPM, BPCI A Convener in BPCI program Trusted Partner Real Results Working with dozens of clients & hundreds of providers across the country Expanding beyond CMS into the commercial and self-insured employer markets All of our partner hospitals & physicians are earning significant savings 4

5 02 BUNDLE PAYMENT OVERVIEW 5

6 What is a Bundled Payment? In a bundled payment model, a single provider is responsible for managing all aspects of care during a discrete episode. Provider as Conductor Bundle Definition Trigger event starts episode (specific DRG or procedure) Defined end date - 90-day episode length Providers are given a bundle-specific Target Price All clinically relevant costs are included in the Target Price Providers share in savings below Target Price Retrospective payment model 6

7 How is Additional Revenue Earned? Example calculation for Major Lower Joint Replacement Case Providers earn additional revenue when actual costs are less than the target price (savings are in addition to traditional surgical billing) 0 5,000 10,000 15,000 20,000 25,000 Target Price 25,000 Price Avg Actual Costs Inpatient Anchor PAC Facility (LTACH, SNF, IRF) Other MD (Hospitalists, Specialty Consults, PCPs) Other (OP, DME) Readmissions Home Health Surgeon 22,000 $3,000 savings per case kept by specialist 7

8 Variation in spending creates opportunity for shared savings Lower Extremity Joint Replacement (DRG 470) Florida has 5 th highest avg post acute spend for MS-DRG 470 8

9 Archway s strategic evaluation identifies opportunities for improvement Major Joint Replacement of the Lower Extremity bundle performance for de-identified surgeons practicing in Florida: Wide variations in average SNF utilization, SNF length of stay, readmission rate, and PAC spending indicate opportunities for improvement.

10 Results: Archway s Practice Partners have tripled their revenue Bundle: Lower Extremity Joint Replacement (DRG 470) Archway Practice A B C # of Surgeons in Practice Annual Volume ,783 Bundled Price $23,161 $25,348 $25,768 Savings per Case $2,491 $3,841 $2,050 New Practice Revenue $525,658 $967,884 $3,654,487 New Revenue per Surgeon $525,658 $80,657 $104,414 10

11 Benefits of Bundled Payments Increased provider autonomy over the care process Years of data from the full continuum Opportunity for to specialty providers participate in an Advanced Alternative Payment Models (APMs) Potential to significantly increase revenue and profitability Non-binding CMS application process 11

12 03 BPCI ADVANCED DETAILS 12

13 BPCI Advanced Model Key takeaways Voluntary program with two anticipated start dates: 10/1/2018 and 1/1/2020 Non binding application due March 12 th for first start date 29 inpatient bundles and 3 outpatient bundles More sophisticated target pricing methodology Qualifies as an Advanced Alternative Payment Model (APM) Under MACRA Episode Initiators can be acute hospitals or Physician Group Practices (PGPs) Quality performance will adjust incentive payments While still non-binding, Application for BPCI Advanced is more robust than recent open window periods 13

14 BPCI Advanced Application Timeline March 12, 2018: Nonbinding application deadline May 2018: Applicants receive data and target prices May July 2018: Applications review data and identify opportunities for success August 2018: Deadline for decision to participate Performance period start date: 10/1/18 14

15 Bundle Definitions 90-day post discharge period for all bundles Retrospective Reconciliation: FFS payments are billed and paid for as usual, and the total FFS payment for the bundle is retrospectively reconciled against a pre-determined target price Semi-annual reconciliation Patients Included: all Medicare FFS beneficiaries Patients Excluded: Beneficiaries covered under Medicare Advantage or United Mine Workers or with Medicare as a secondary payers; ESRD eligible beneficiaries; beneficiaries who die during the Anchor Stay or Anchor Procedure. CJR bundles take precedence over BPCI Advanced bundles Next Gen ACO attributed patients do not count in BPCI Advanced 15

16 Costs included in the bundle Costs included: all clinically relevant Part A & B items and services furnished during and following the anchor stay/procedure, including: Physicians services, other hospital outpatient services, readmissions, LTCH, IRF, SNF, home health agency, Clinical lab, DME, Part B drugs, and hospice [new] IP bundles also include: diagnostic testing and certain therapeutic services furnished in three days prior to the Anchor Stay Charges from an ED visit at another hospital if the beneficiary is transferred the day of or before admission for the anchor stay [new] Costs excluded: costs for clinically unrelated services including major trauma, cancerrelated care, organ transplants, ventricular shunts, blood clotting factors IPPS New technology add-on payments OPPS pass-through payments 16

17 Bundles in BPCI Advanced Inpatient bundles anchored by MS-DRGs Ø 10 Ortho: MJRLE; MJRUE; Double JRLE; Fractures of femur/hip/pelvis; Hip & femur procedures except MJ; Lower extremity/ humerus procedure except hip, foot, femur; Spinal fusion (non-cervical); Cervical spinal fusion; Back & neck except spinal fusion; Combined anterior posterior spinal fusion Ø 8 Cardiac: AMI, CHF, Cardiac arrhythmia, Cardiac defibrillator, Cardiac valve, CABG, Pacemaker, PCI Ø 3 GI: GI hemorrhage; GI obstruction, Major bowel procedure Ø 2 Respiratory: COPD, bronchitis, asthma; Simple pneumonia and respiratory infections Ø Other: Cellulitis; Renal failure; Sepsis; Stroke, UTI Ø New: Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis Outpatient bundles identified by HCPCS PCI IP bundles represent >55% of all IP expenditures, or $70+ billion in annual national spends. Under BPCI Advanced, this represents $2+ billion in savings for CMS and up to $15 billion of shared savings for providers Cardiac Defibrillator Back & Neck except Spinal Fusion Beginning 1/1/2020: CMS may add or remove bundles on an annual basis 17

18 Target pricing Detailed methodology forthcoming from CMS Benchmark price: calculated based on a combination of historical Medicare FFS spending, adjusted to reflect the Episode Initiator s efficiency relative to its peers over time, along with adjustments for patient characteristics and regional spending trends Target price: 3% discount to Benchmark Price 3% discount subject to change in future Model Years Each hospital Episode Initiator receives its own Target Price for each Bundle PGPs will be assigned a target price specific to the acute hospital where the anchor procedure is performed; the target price will be adjusted by PGP-specific adjustments A preliminary Target Price will be determined prospectively, and a final Target Price set retrospectively at the time of Reconciliation based on actual patient case mix CMS will apply Winsorization at the 1 st /99 th percentile to trim outlier spend 18

19 Reconciliation During semi-annual reconciliation, aggregate clinical spending for each bundle will be compared to the target price If spending is lower than the target price, participants receive a positive reconciliation amount (i.e. bonus payment) If spending is higher than the target price, participates receive a negative reconciliation amount (i.e. repayment to CMS) 20% stop-gain and stop-loss is applied at Episode Initiator Level 19

20 Adjusting Payment by Quality Performance Quality score will be calculated for each measure for each bundle Scores will be aggregated across all bundles for a given Episode Initiator, weighted by volume and measure, to generate Episode Initiator-specific Composite Quality Score (CQS) Outcome measures weighted more than process measures A CQS Adjustment Amount will be applied to bonus or repayment amount For first two years, there is 10% cap on the amount to which CQS can adjust bonus or repayment 20

21 Quality Measures Claim-based measures required and collected by CMS starting 10/1/2018: 1. All-cause Hospital Readmission Measure required for all bundles 2. Advanced Care Plan required for all bundles 3. Perioperative Care: Selection of Prophylactic Antibiotic: 1 st or 2 nd Generation Cephalosporin 4. Hospital-Level Risk-Standardized Complication Rate Following Elective Primary THA/TKA 5. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG 6. Excess Days in Acute Care after Hospitalization AMI 7. AHRQ Patient Safety Indicators (PSI 90) 21

22 Quality Measures Claim-based measures required and collected by CMS starting 10/1/2018: 1. All-cause Hospital Readmission Measure required for all bundles 2. Advanced Care Plan required for all bundles 3. Perioperative Care: Selection of Prophylactic Antibiotic: 1 st or 2 nd Generation Cephalosporin 4. Hospital-Level Risk-Standardized Complication Rate Following Elective Primary THA/TKA 5. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG 6. Excess Days in Acute Care after Hospitalization AMI 7. AHRQ Patient Safety Indicators (PSI 90) Additional measures that may be required starting 1/1/ CAHPS for Clinicians 2. CAHPS for Hospitals 3. CAHPS Home Health Care 4. Hypertension: Improvement in Blood Pressure 5. Drug Regimen Review with Follow-up 6. Surgical Site Infection 7. Unplanned Reoperation within 30 Day Postop Period For non claims based measures, participants must report quality data by February 20 of the following year E.g. by February 20, 2021, Participants must report on all applicable quality measures for all of Participants can receive historical quality data by submitting nonbinding application 22

23 BPCI Advanced provides physicians an opportunity to qualify for MACRA s Advanced-APMs Payment Track BPCI Advanced will not qualify physicians for Advanced APMs track until MACRA Year 3, corresponding with Performance year 2019 and Payment Year 2020 MIPS Default payment track Quality reporting requirements MACRA forces physicians into one of two Medicare FFS payment tracks Upside/downside payment adjustment based on relative quality performance; two-sided risk increases from ±4% to ±9% over time Budget neutral nationwide (i.e. forced winners & losers) 5% annual lump sum bonus A-APMs Requires participation in Advanced Alternative Payment Model (i.e. BPCI-Advanced) Quality reporting requirement fulfilled through BPCI Advanced participation Requires minimum % of Medicare payments or Medicare patients in risk arrangement 23

24 12 Components of BPCI Advanced Application, Due March 12 th 30+ Narrative questions Each component has several narrative questions: 1. Organization Information, including CEHRT attestation, participant list, and executive summary of application 2. Practitioner Engagement including plan for consent, retention, and adherence for care redesign 3. Care Improvement plan for care redesign care processes in evidence-based medicine, beneficiary/caregiver engagement, quality and care coordination, including readiness assessment 4. NPRA Sharing experience in gainsharing and P4P initiatives, and proposed methodology for BPCI Advanced gainsharing 5. Quality Improvement including experience in improvement interventions and plan for quality improvement in BPCI A 6. Quality Assurance Approach to ensure clinical appropriateness, including Sanctions, Investigations, Probations, or Corrective Action Plans 7. Beneficiary Protections plan for beneficiary protection, education, engagement 8. Financial Arrangements- planned gainsharing arrangements and funds flow mechanism 9. Organizational Capabilities and Readiness 10. Partnerships business relationships 11. Data Request & Attestation 12. Certification 24

25 04 HOW TO GET STARTED 25

26 Archway Support Process Contact Archway Sign our Good Faith Agreement Preliminary Opportunity Assessment BPCI-A Application Due March 12 Call or Archway Share some basic information Determine interest in evaluating opportunity & submitting nonbinding LOI to CMS Non-binding letter that explains how Archway and your practice will engage to apply for BPCI Receive detailed analysis on your organization s risks and opportunities using our Archway Analytics platform. Work with Archway to submit your application and request your data 26

27 Archway Academy 27

28 QUESTIONS?