Cardiac Bundle (AMI, CABG, and SHFFT), CR and ACO Track 1+ January 11, 2017

Transcription

1 To Dial-in: or Event Number: Cardiac Bundle (AMI, CABG, and SHFFT), CR and ACO Track 1+ January 11, 2017

2 CMS Final Rule and Materials Advancing Care Coordination through Episode Payment Models Final Rule (CMS-5519-F) and Medicare ACO Track 1+ Model CMS Final Rule CMS Fact Sheet CMS Episode Payment Model page: Acute Myocardial Infarction (AMI) model parameters: Coronary artery bypass grafting (CABG) model parameters: Surgical hip/femur fracture treatment (SHFFT) model parameters:

3 Model Overview 5-year demonstration running from July 1, 2017 December 31, 2021 Estimated savings of $159 million AMI: CABG/PCI: 98 MSAs and 1,120 hospitals SHFFT: 67 CJR MSAs and 860 hospitals CR: 90 MSAs (45 overlap with AMI & CABG) and 1,320 hospitals

4 Episode Length and Diagnosis Related Groups Demonstration is for IPPS hospitalizations Fee for service Part A and Part B reimbursement MSAs selected randomly Anchor hospitalization plus 90 days post acute AMI: DRG PCI: DRG CABG: DRG SHFFT: DRG Exemptions: Death during anchor hospitalization Beneficiary discharged from a final transfer hospital that could not initiate episode payment model Canceled if beneficiary initiates a BPCI model episode

5 Target Pricing Pricing consistent with Comprehensive Care for Joint Replacement Model (CJR) PY 1: 1/3 PY 2: 2/3 PY 4-5: 100% Regional pricing (9 census divisions) increases year over payment year (PY) and will not be used for historically low EPM volume and for hospitals that merge Exceptions: Regional only for low historic episode volume: SHFTT less than 50 historic episodes over 3 years; AMI less than 75; AMI anchored by PCI less than 125; CABG less than 50 Discount factor determined by quality performance. No discount in PY 1 and 2: For acceptable quality performance and below: 3% For good quality performance: 2% For excellent quality performance: 1.5% No risk adjustment for beneficiary demographic characteristics and clinical indicators

6 Financial Performance Providers earn a composite performance score Minimum performance level must be met before receiving reconciliation payments Year over year improvement bonus is 10% Performance results publically available on Hospital Compare Below acceptable requires repayment beginning PY 3 Quality must be Acceptable or better

7 Quality Performance Measurement AIM Measures 30-day all cause mortality Excess days in acute care HCAPHS survey Scoring: Fed. Reg. Table 24 CABG Measures 30-day all cause mortality HCAPHS survey Voluntary reporting of STS composite score Scoring: Fed. Reg. Tables SHFFT measures Total Hip/Total Knee Arthroplasty complications HCAPHS survey Scoring: Fed. Reg. Tables Data collection via Quality Reporting Document Architecture (QRDA-I) or spreadsheet for PY 1 EHR data only through QRDA-I for PY 2-5

8 Reconciliation, Gain Sharing, and Accounting for Overlap Reconciliation Payments Retrospective annual payments No repayment first 2 years (no mandatory downside risk) Reduced discount % for repayment responsibility in PY 3 and PY 4 PY 1, 2, 3: 5% of target price possible PY 4: 10% of target price PY 5: 20% of target price Stop loss/gains lower for rural, low-volume, Medicare-dependent, sole-community, a rural referral centers Gain Sharing Hospitals can share with ACOs, CAHs and PGPs Partners can be responsible for percent of repayment For ACO beneficiaries reconciliation payments added to ACO expenditures when hospital and ACO are partners. Non-aligned ACOs may keep windfall benefit

9 Reconciliation Payment Details Downside risk begins for episodes ending on or after January 1, 2019 through PY 5 Stop loss and gains vary by performance year: 5% in PY 3 (3% for select hospitals, such as CAHs) 10% in PY 4 (5% for CAHs) 20% in PY 5 (5% for CAHs) Discount percent ranges for reconciliation based on quality 0.5% to 2.0% for PY 3 and PY 4 1.5% to 3.0% for PY 5 May volunteer for downside risk for episodes ending on or after January 1, 2018 (PY 2). Stop loss is 5% Discount percent is 0.5% to 2.0%

10 Additional Reconciliation Payment Details CMS will cap high payment episodes CMS anticipates employing risk adjustment in PY 3 See Fed. Reg. Tables for AMI, CABG, and SHFFT pricing scenarios See page Fed. Reg for payment reconciliation

11 Waivers SNF Telehealth Home Visits Patient Engagement CR Non-Physician Providers No 3 days inpatient stay required Originating site requirement waived Physician-directed post-discharge inhome visits permitted In-kind patient incentives permitted NPs, CNAs, PAs may perform select physician functions Effective for episodes beginning on or after April 1, 2018 Geographic site requirement waived In-Home visits allowed for all 3 EPMs Up to 13 for AMI 9 for CABG and SHFFT No Fraud and Abuse Waivers

12 Exclusions ACO Next Generation BPCI Models for AMI, CABG or SHFFT ACO Track 3 Comprehensive ESRD Care Model Maryland and Vermont

13 Alternative Payment Model CJR Track 1 Meets financial risk Uses CEHRT Qualifies as APM CJR Track 2 Does not meet APM requirements

14 Beneficiary Protections and Incentives Retains right to obtain services from any qualified provider May not opt out of model Provided written information on model design May be provided with incentives reasonably connected to care: Technology related items or services not to exceed $1,000 Good faith effort required to recover items more than $100 in retail value

15 Cardiac Rehabilitation Incentive Payment Model Encourage care coordination greater utilization of cardiac and/or intensive cardiac rehabilitation post AMI or CABG discharge Secondary prevention and risk reduction therapy improve quality of life and reduce risk of hospital admission, but are underutilized Includes smoking cessation, blood pressure and cholesterol monitoring Only 35% of AMI patient receive CR services Barriers include: low referral rates, lack of awareness; financial burden on beneficiaries; Medicare physician supervision requirements Model provides financial incentives to provide CR/ICR services for 90 days post discharge for AMI or CABG patients

16 Cardiac Rehabilitation Incentive Payment Model Anchor hospital financially accountable for the AMI or CAMG episode Implemented in 90 MSAs 45 MSAs for EPM-CR hospitals Another 45 MSAs for FFS-CR hospitals CMS estimates 1320 hospitals will participate in the CR model CR/ICR services identified by PFS or OPPS claims with HCPCS codes: 93797, 93798, G0422, G0423 All CR/ICR services paid under OPPS will be included. PFS claims must have place of service code 11 to count toward CR incentive payments

17 Cardiac Rehabilitation Incentive Payment Model: Payment Details AMI and CABG models take precedence Two-part retrospective payment based on total CR use Initial $25 in incentive payment for each of the first 11 rehab sessions for AMI and CABG $175 per service beyond the 11th session These sessions must fall within 90-day bundled period window EMP-CR Model includes waiver to all Physician Assistant, Nurse Practitioner and Clinical Nurse Specialist to: Perform specific HCPCS code physician functions Prescribe exercise Create individual treatment plans

18 Cardiac Rehabilitation Incentive Payment Model: Additional Details Incentive Payment Report: Annual report on number of episodes, number of CR/ICR services, CR payments, etc. Dispute Resolution Process: 45 days to provide notice to CMS. CMS reconsideration is final and binding Model begins July 1, 2017 and runs through December 31, 2021

19 ACO Track 1+ Details (To Date) Track 1+ model available for 2018, 2019, and 2020 application cycles Open to current Track 1 (when renewing and during agreement period) and first time ACO participants Can participate in Track 1+ for only one 3-year agreement period Maximum 50% in earned shared savings and fixed 30% loss sharing rate Financial benchmarking will incorporate regional spending factor Beneficiaries are prospectively assigned Choice of symmetrical MLR/MSR thresholds to begin receiving shared savings or losses (same MLR/MSR as Track 2 and Track 3) SNF Waivers available Track 1+ notice of intent letters are due May 2017 CMS fact sheet available (Additional details forthcoming)

20 ACO Track 1+ Financial Risk Thresholds Two risk arrangements (either revenue or benchmark based loss sharing limits) Determined by three criteria: 1. ACO is owned or operated by a hospital, cancer center, or rural hospital with more than 100 beds 2. ACO is owned or operated by a rural hospital with 100 or fewer beds 3. Rural hospital with ACO with 100 or fewer beds owned or operated by a health system If none of these criteria are met ACO loss sharing limit would be 8% of revenue in Year 1. Note: In years 2 or 3, revenue threshold must align with MACRA s Quality Payment Program s definition of nominal risk should it change to maintain Advanced APM status. If at least one of these criteria are met ACO loss sharing limit would be 4% of the ACO s updated historical benchmark

21 Thank You AMGA Regulatory Team: David Introcaso: Darryl Drevna: