CMS Cardiac (AMI & CABG), SHFFT and Cardiac Rehab. Demo - Overview September 13, 2016
Cardiac (AMI & CABG), SHFFT (Surgical Hip/Femur Fracture Treatment) & Cardiac Rehabilitation Demo Why expand Comprehensive Care for Joint Replacement (CJR) demo High volume & high expenditure: 168,000 AMIs, 48,000 CABGs and 109,000 SHFFTs at $4.1b., $3.2b. & $4.7b. respectively Hospital readmissions: E.g., 20% of AMIs w/in 30 days Variation in reimbursement is as great as 50% SHFFT: (includes neck of the femur) w/shfft to include (under the CJR demo) all surgical treatment options for hip fractures (5-10% mortality after 1 mo. & 33% after 1 yr.) Cardiac rehabilitation: though shown to reduce subsequent heart attack events, is substantially under-utilized, e.g., only 50% of patients had 25 or more CR sessions
Mandatory Participation & Locations CMS is proposing a five-year ('17-'21), mandatory demonstration Bundle payments for Parts A & B for AMIs treated medically (& revascularization via PCI), CABG & SHFFT for inpatient hosp. & ends 90 days after date of discharge from anchor hospitalization Begins July 2017 in 98 (out of 294) randomly selected geographic regions or Metropolitan Statistical Areas (MSAs) AMI & CABG in the same MSAs, SHFFT in CJR MSAs, CR in same and different MSAs CMS does not identify the 98 MSAs but does ID 90 MSAs that would be excluded
Overlap, MSA Exclusions and Episode Payment Model (EPM) Cancellations Overlap: BPCI hospitals in models 2 and 3 for relevant episodes and Next Generation and Comprehensive ESRD Care demos are excluded Exclusions: MSAs with fewer than 75 AMI episodes in the reference yr. (eliminates 49 MSAs) (can include MSAs w/no CABGs) & when non-bpci AMIs are less than 50% of the 75 When EPM is cancelled: Bene. dies during the anchor hospitalization (unlike CJR where canceled w/death at any time) or when bene. initiates any BPCI episode
CEHRT Requirement (related to the MACRA APM Pathway) Required to meet CEHRT, i.e., to be able to meet advanced APM criteria EPMs in two tracks: Track 1 w/cehrt and financial risk will qualify for the 5% advanced APM bonus; and, Track 2 will not.
Target Price Calculation CMS proposes to generally apply CJR method Three yrs. of historical data ('13-'15): 2/3rds hist. & 1/3rd regional first 2 yrs., 1/3 and 2/3rd for 3 rd yr. & all regional 4th and 5 th yr. (Region based on the 9 census divisions) (will apply a high pymt. ceiling at 2 standard deviations above regional level), will apply a national trend factor as in CJR Proposing a 3% discount generally & 2% & 1.5% for good and excellent quality respectively Proposing to include reconciliation pymts. when updating EPM target prices/quality adjusted target prices No repayment for 1 st yr., partial repayment 2 nd yr. (beg. end of 2 Nd qtr. or 5/18) No risk adj. based on bene. specific demo characteristics or clinical indicators Stop gain & loss are symmetrical: from 5/18-12/18 at 5%, for '19 at 10% & for '20- '21 at 20% (separate loss limits for certain hospitals, e.g., rural) Reconciliation 2 mons. after the performance year concludes
Quality Measures & Scoring Similar/same measures and quality scoring as CJR AMI: 30 day all cause mortality; hospital excess days and HCAHPS survey CABG: 30 day all cause mortality & HCAHPS SHFFT: same as CJR: complication rate, HCAPHS & successful voluntary reporting of patient reported outcomes Bonus pts. for year-over-year improvement Scoring: measures are weighted (e.g., AMI 50% for mortality, 25% for excess days and 20% HCAHPS) & will add 10% for each quality measure to which improvement could apply
Payment Waivers & Data Sharing Similar/same as CJR Telehealth Post discharge nursing visits (AMI up to 13, CABG & SHFFT up to 9) SNF waiver beginning 4/'18 (w/at least 3 stars for 7 of last 12 months) Expanded Use of mid-levels re: cardiac rehab. Data Share upon request raw claims-level data & claims summary data & 3rs. of retrospective data upon request
Overlap w/other P4P programs (e.g., ACOs) & other demos It would be difficult for CMS at this time to provide standard program or model rules that would fairly distribute savings among different models & programs for overlapping periods of bene. care. Savings achieved during the EPM are attributed to the ACO as expenditures when the bene. is aligned w/the ACO If the EPM bene. is also an assigned ACO bene., CMS will add to any reconciliation pymt. the discount $s when it is paid back in shared savings to a hospital that is also an ACO If the hospital is not aligned w/the ACO, CMS will allow the ACO to benefit (in its reconciled expenditures) from the EPM episode discount
Collaboration in re: alignment payment (gainsharing), bene. incentives & transparency Similar to CJR, i.e., SNFs, HHAs, LTHCs, IRFs, et al., & w/the addition of ACOs, CAHs and hospitals Technology/ical devices to improve care can be provided the bene., not to exceed $1,000 and for $100 or more, the technology must be retrieved at the end of the EPM episode Transparency Re: selection bias, CMS will publish claims data comparing each EPM participants pre-demo utilization against demo utilizations
Cardiac Rehab (CR) & Intensive Cardiac Rehab (ICR) For EPM-CR hospitals in 45 MSAs and for FFS-CR hospitals in another 45 MSAs (7/17 through 12/21) CMS would provide retrospectively $25 in incentive pymts. per bene. for each of the first 11 rehab sessions for AMI and CABG, services beyond the 11th session would be increased to $175 (total # is not capped), pymt. distinct from EPM (not factored in calculating EPMs & not a part of reconciliation sharing arrangements Waiver to allow PA, NP and CNS to perform specific HCPCS code physician functions, e.g., prescribing exercise, creating ind. treatment plans & will allow for transportation services
Savings, Estimated Impact CMS estimates savings at $170m. out of $13.8b., or 1.2% in total episode spending
Thank You The proposed rule (346 pgs.) is at: https://www.gpo.gov/fdsys/pkg/fr-2016-08- 02/pdf/2016-17733.pdf. AMGA Regulatory Team: David Introcaso: dintrocaso@amga.org Darryl Drevna: ddrevna@amga.org Garrett Eberhardt: geberhardt@amga.org