Home Health Value-Based Purchasing. April 6, :00-3:45 pm

(1)

Home Health Value-Based

Purchasing

April 6, 2016

12:00-3:45 pm

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• Understand the changing health care landscape, including various models of value-based purchasing

• Learn how the HHVBP demo program is shaping care delivery—and what it means for your agency

• Identify risks and opportunities for your agency

• Share best practices, resources, and member experiences

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• Welcome & Introductions

• Health System Transformation and Innovation

• HH VBP Demonstration Program Overview

• Implementing VBP: Performance Modeling and

Readiness

• Readiness Exercise

• Putting It In Practice: Member Experiences

• Tools and Resources

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• Health system reorienting towards value

• Value-based purchasing (VBP) can improve

coordination and health outcomes

• Payers (including Medicare) and providers are

working together on innovative delivery system

reforms

• Home Health can play a critical role in many care

delivery models

(6)

In January 2015, HHS announced:

• Aggressive shift from volume-based to

value-based payment for Medicare

• Goal: 85% of Medicare FFS payments tied to

performance by end of 2016

• Goal: Transition at least 30% of all FFS

payments to alternative payments (inc shared

savings and bundles) by end of 2016.

(7)

Pay-for-Performance Care Coordination Shared Savings Bundled Payments Capitation

Common “alternative” payment models

• Pay for Performance (P4P)

• Care Coordination

• Shared Savings

• Bundled Payments

• Capitation

(8)

Description Delivery System Alignment

• A portion of a provider's payment is based on its performance on established metrics of quality, health outcomes, and efficiency • Maintains existing FFS payment

structure

• Payers and providers must

identify performance metrics and providers must develop systems and capacity to collect and track data

All providers and delivery system models

(9)

• Payers generally reimburse care coordination services on a PMPM fee

• Payment varies by service provided; risk level of patient • Providers deliver all care

coordination services in the month

Primary Care Medical Homes; Health Homes; ACOs

(10)

• Payers and Providers agree to a

spending target for a set of services; Payer monitors cost of services against spending target

• If costs are less than targets, providers may be eligible to share in savings generated

• If cost of care is more than target,

providers may be required to reimburse payer

• Quality/health outcome standards

ACOs; Retroactive Bundled Payment Models; PCMH

(11)

• Payers pay a single price for a set of services for a given condition • Provider is responsible for paying

the other providers who treated the patient during the episode of care

• Providers only responsible or covering the costs of services associated with that one

condition

Prospective Bundled Payment models

(12)

• Payers pay a single PMPM for a set of services for a designated population

MCOs; Primary Care Providers

(13)

• ACO Models



Pioneer ACO: Certified for expansion



Next Generation ACO Model

• Bundled Payment Models



Comprehensive Care for Joint Replacement (CCJR)

• Value-based Purchasing



HH Value-based purchasing demo



SNF Value-based purchasing program

(14)

• MedPAC’s Unified Payment System for PAC

(proposed)

• SFC Chronic Care Working Group (pending)

• Implementation of IMPACT Act

(15)

GOALS:

• Comparison across post-acute/long-term care

• Improved quality – care and outcomes

• Improved communication and interoperability

• Recommendations on payment reform Methods:

• Selectively standardize: assessment data, data for QMs, and data on resource use

• Replace some elements of current assessments (OASIS , MDS, IRF-PAI, LTCH)

• Assess at admission and discharge

(16)

Tool Kit Overview

Alternative Delivery and Payment Models Sample Performance Metrics

Risk Management

Comprehensive Care for Joint Replacement HH Compare Star Ratings

(17)

Home Health Value Based

Purchasing Demo

(18)

CMS published the final rule for HHVBP Model in November 2015. The model:

• Incentivizes Medicare HHAs to provide higher quality and more efficient care;

• Tests whether a payment incentive of up to 8% significantly improves provider performance;

• Test the use of new quality measures in the home health setting;

• Updates the current public reporting process.

(19)

The model includes ALL Medicare-certified HHAs

in nine states:

HHVBP: Background

• Arizona

• Florida

• Iowa

• Maryland

• Massachusetts • Nebraska

• North

Carolina

(20)

• Demo began January 1, 2016 and runs through CY 2022

• Payment adjustments tied to quality performance

• HHAs are scored based on quality of care delivered to all patients receiving services compared to:

 Performance of their peers within their state, defined by the same size cohort, and

 Their own past performance on the measures.

(21)

HHVBP: Background

Data Collection Data Submission/Reporting Quality Improvement Activities Quarterly Performance Reports Quality Improvement Activities Total Performance Score Annual Payment Adjustment

(22)

• Calendar year 2015 will serve as the baseline year

 Not readjusted during the demo

• Performance Years of the model are 2016, 2017, 2017, 2019, 2020

• Individual HHAs will be measured against a cohort of similar agencies in the state

• HHAs will be measured against a benchmark performance measure standard

(23)

• 6 process measures from existing OASIS data collection

• 8 outcome measures from existing OASIS data and 2 outcome measures from claims data

• 5 HHCAHPS consumer satisfaction measures

• 3 new measures

 Points achieved by reporting data

 Submitted through the HHVBP portal

(24)

• Cohort is the grouping in which individual HHAs are competing

• Cohorts defined by states and, in some states by HHA size

 60+ beneficiaries in a calendar year

 59 or fewer beneficiaries in a calendar year

(25)

• Benchmark is the performance measurement goal for HHAs

• Benchmark is calculated as the mean of the best 10% of all HHAs within a cohort in the baseline year

(26)

• HHA receive Achievement Points for each measure for its own performance against the benchmark

• HHAs receive Improvement Points for a measure based on its change in performance relative to baseline year

• Points range from 0-10

Total Performance Score takes the HIGHER of

Achievement or Improvement points for EACH measure

(27)

• TPS summarizes an individual HHAs performance on quality measures relative to other HHAs in its cohort AND its own baseline year.

• TPS include if HHAs report data on New Measures

• TPS used to determine payment adjustment

• TPS calculated by summing the points for each measure and adjusting for number of measures available

(28)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first

New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect

(Up to 3%)

(29)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(30)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(31)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(32)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first

New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(33)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure

submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(34)

Jan-Dec 2015: Baseline Performanc e Period Jan 1, 2016 Performanc e Year 1 Begins April 2016 Achievemen t Thresholds & Benchmarks Available July 2016: First Quarterly Performanc e Report Available Oct 2016 Quarterly Performanc e report and first New Measure submission

Summer 2017: First Draft Payment Adjustment Report Available; 30

Days to Submit Revisions

Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performanc e Goes Into Effect (Up to 3%)

Total Performance Score (TPS)

(35)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available Jan 2018: Payment Adjustment Based on Year 1 Performance Goes Into Effect (Up to 3%)

(36)

Jan-Dec 2015: Baseline Performance Period Jan 1, 2016 Performance Year 1 Begins April 2016 Achievement Thresholds & Benchmarks Available July 2016: First Quarterly Performance Report Available Oct 2016 Quarterly Performance report and first New Measure submission Summer 2017: First Draft Payment Adjustment Report Available; 30 Days to Submit Revisions Nov 2017: Final Payment Adjustment Report Available

Jan 2018: Payment Adjustment Based on Year 1 Performance

Goes Into Effect (Up to 3%)

(37)

Portal provides access to:

• Submission of new measures • Performance results

• All communications/webinars • Website resources

ALL Medicare-certified HHAs must provide a primary contact AND register for portal

(38)

Value Based Purchasing

Overview of Performance Model and Calculations

Chris Attaya

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Each Measure will have points scored based on the higher of an achievement score or improvement score

• Using the Base Year Period two calculations are set

• Threshold Value – 50th_{percentile (Median)}

• Benchmark – Mean of the top decile (~95 percentile)

• Base Year (Calendar Year 2015) will not change

• Performance Years 2016 – 2020

• Each measure needs 20 or more episodes to be included in the total performance scores

• New Measures will be scored based on self reporting data only

Measure Points Scoring

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Measure Points Scoring

(cont.)

(41)

• Awarded by comparing an individual home health agency’s rates during the performance period with all home health agency’s rates from the baseline period

– Rate equal to or better than the benchmark: 10 points – Rate less than the achievement threshold: 0 points

– Rate equal to or better than the achievement threshold and worse than the benchmark: 0 – 10 points

Measure Points Scoring

(cont.)

Achievement Points – By Pilot State

(42)

• Awarded by comparing an individual home health agency’s (HHA’s) rates during the performance period with that same individual HHA’s rates from the baseline period.

– Rate equal to or better than the benchmark: 10 points – Rate worse than the agency’s base year rate: 0 points – Rate equal to or better than the agency’s base year

rate and worse than the benchmark: 0 – 10 points

Measure Points Scoring

(cont.)

Improvement Points – By Agency

(43)

Measure Points Scoring

(cont.)

(44)

Achievement Calculation

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Improvement Calculation

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Total Performance Scoring (TPS)

• CMS proposing that TPS and payment adjustments would be calculated based on an HHA’s CCN and therefore, based only on services provided in the selected states

• 21 OASIS/HHCAHPS/Claims based measures will be used in the TPS unless the an agency does not have 20 or more episodes per measure (Accounts for 90% of the score)

• Three New Measures will account for the 10% of the score

• If an HHA does not meet this threshold to generate scores on five or more of the Clinical Quality of Care, Outcome and Efficiency, and Person and Caregiver-Centered Experience measures, no payment adjustment will be made

(47)

Total Performance Scoring (TPS)

(cont.)

47

(48)

Scores on 16 available OASIS/HHCAHPS measures = 88 Points

• HHA 1’s total possible points would be calculated by

multiplying the total number of measures for which the HHA reported on least 20 (twenty) episodes by the

maximum number of points for those measures ten (10), yielding a total of 160 possible points

• 88 points divided by the total 160 = .55

• .55 points X 90 = 49.5

• New Measures – all three entered equals 30 points out of a maximum of 30 = 1.0 X 10 points = 10 points

• Total Points = 59.5

48

(49)

• For each New Measure, HHAs will receive 10 points if they report the New Measure or 0 points if they do not report the measure.

• New Measures will account for 10% of the TPS regardless of the number of measures applied to an HHA in the other 3 classifications.

Examples: 3 measures entered would be awarded 10 points 2 of the 3 measures would be awarded 6.667 points

• Points will be prorated if new measures entered for one quarter are different than other quarters

New Measure Scoring

(50)

• Each agency’s value-based incentive payment amount for a fiscal year will depend on:

 Range and distribution of agency total performance scores

 Amount of agency's base operating HHRG payment amount

• The value-based incentive payment amount for each agency will be applied as an adjustment to the base operating HHRG payment amount for each episode

Net Reimbursement Impacts

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• CMS will use a linear exchange function (LEF) to distribute the available amount of value-based incentive payments to agencies, based on agency’s total performance scores on the HHVBP measures

(52)

CMS HHVBP Impact Reporting

• Distribution of the Payment Adjustments in the different model years

(53)

CMS HHVBP Impact Reporting

(cont.)

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CMS HHVBP Impact Reporting

(cont.)

(54)

LEF Distribution Examples

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(55)

LEF Distribution Examples

(cont.)

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(56)

LEF Distribution Examples

(cont.)

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(57)

LEF Distribution Examples

(cont.)

(58)

LEF Distribution Examples

(cont.)

(59)

Trended SHP HHC VBP scores in NC

(60)

Trended SHP HHC VBP scores in NC

(Cont.)

(61)

Trended SHP HHC VBP scores in NC

(Cont.)

(62)

• Develop or obtain a tool to organize data for

easy reference to domain, measure, data sources etc.

• Verify data from all sources

• Insert proxy data for any missing variables

• Make reasonable assumptions on outcome trends

• Determine your risk tolerance

• Create a model to test your assumptions

The Foundation of Analysis is Accurate Data

(63)

What-if Sensitivity Analysis

(64)

Greatest Opportunity to Improve

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Example: Improvement in Dyspnea

Model 1 – Run Rate from CY 2015

Model 2 – Lowest Performers reach Agency median

(65)

Greatest Opportunity to Improve

(Cont.)

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• What-if all clinicians improve by X% point?

 Or elevate lowest 50th_{percentile to median}

• What are the easier measures to change?

 PM’s Outcomes HHCAHPS

 Is there best practices already in my agency

• At what cost – Return on Investment (ROI)?

 $1,000,000 Medicare revenue = $30,000 risk first year  What is the opportunity cost – of not doing something?

(66)

Greatest Opportunity to Improve

(Cont.)

(67)

• Quarter 1 is closed – Your agencies CY 2016 performance will include a 25% share of those scores

• Set goals for each quarter – hitting your target by year-end is good but remember it is a year-to-date calculation

• Be careful of analysis paralysis

• Pick the top 2 – 4 measures to focus on – not on all 21

• Improvement in Star Rating measures are a Two-fer

Keys to Watch Out For

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