State Payment Reform Bringing physicians together for a healthier Ohio *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 1
5-Year Goal for Payment Innovation Patient-centered medical homes Episode-based payments Goal 80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years Year 1 In 2014 focus on Comprehensive Primary Care Initiative (CPCi) Payers agree to participate in design for elements where standardization and/or alignment is critical Multi-payer group begins enrollment strategy for one additional market Year 3 Year 5 State leads design of five episodes: asthma acute exacerbation, perinatal, COPD exacerbation, PCI, and joint replacement Payers agree to participate in design process, launch reporting on at least 3 of 5 episodes in 2014 and tie to payment within year Model rolled out to all major markets 50% of patients are enrolled 20 episodes defined and launched across payers Scale achieved state-wide 80% of patients are enrolled 50+ episodes defined and launched across payers State’s Role Shift rapidly to PCMH and episode model in Medicaid fee-for-service Require Medicaid MCO partners to participate and implement Incorporate into contracts of MCOs for state employee benefit program Overall, the 5-year focus at the state level is on PCMH and episodes. For immediate term, the focus is on CPCI for PCMH and development of 5 episode models (with the goal to launch reports in November 2014). Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Bringing physicians together for a healthier Ohio
Ohio Comprehensive Care Initiative *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 15
Episodes of Care Bringing physicians together for a healthier Ohio 16 *Add footers & “Exhibit” references Bringing physicians together for a healthier Ohio 16
Retrospective episode model mechanics Patients seek care and select providers as they do today Providers submit claims as they do today Payers reimburse for all services as they do today 1 2 3 Patients and providers continue to deliver care as they do today Providers may: Share savings: if average costs below commendable levels and quality targets are met Pay part of excess cost: if average costs are above acceptable level See no change in pay: if average costs are between commendable and acceptable levels Review claims from the performance period to identify a ‘Principal Accountable Provider’ (PAP) for each episode 4 5 6 Calculate incentive payments based on outcomes after close of 12 month performance period Payers calculate average cost per episode for each PAP1 Compare average costs to predetermined ‘’commendable’ and ‘acceptable’ levels2 Ohio episode model is RETROSPECTIVE, not prospective. To repeat, there is not pre-set price for a bundle in the retrospective model. Patients seek care and providers bill and are reimbursed as they do today. After the fact, claims data is analyzed to: - identify the principal accountable provider, or PAP, who is held accountable for all episode costs, not just those he/she directly bills for - calculate the average episode code per PAP and compare to set “commendable” and “acceptable” thresholds to determine any gain or risk sharing Bringing physicians together for a healthier Ohio
Retrospective thresholds reward cost-efficient, high-quality care 7 Provider cost distribution (average episode cost per provider) Eligible for gain sharing based on cost, didn’t pass quality metrics Gain sharing No change Risk sharing Ave. cost per Episode $ - Risk sharing Pay portion of excess costs No change in payment to providers + Gain sharing Eligible for incentive payment Acceptable ILLUSTRATIVE Commendable ILLUSTRATIVE Gain sharing limit here is 1 bar for each principal accountable provider. The height of the bar represents that PAP’s average episode cost across all their episodes in a given time frame, after adjustments have been applied (i.e., risk adjustment, outlier and other exclusions). The bars are ordered from left to right, from the PAP with the highest average episode cost to the PAP with the lowest average episode cost. If a PAP’s average cost is above a pre-set “acceptable” threshold (those in red, on the left), they may be at risk and pay back some of the cost to the payer. If a PAP’s average cost is below a pre-set “commendable” threshold (those in green, on the right), they may share in the savings. However, if these low-cost PAPs have an average episode cost below a gain-sharing limit, their savings will be capped, to reduce the incentive to limit care. In addition, PAPs must also achieve certain clinical quality metrics (defined for each episode) to receive gain-sharing. The blue bars indicate PAPs who met the cost requirements for gain sharing but did not meet the quality requirements. This model rewards both absolute performance – with shared savings for those who are already performing commendably - and performance improvement, with potential for gain-sharing (or to move out of risk-sharing) as PAPs improve. The thresholds are not meant to be constantly moving targets, but to give everyone a chance to improve performance and realize gain-sharing. Principal Accountable Provider SOURCE: Arkansas Payment Improvement Initiative; each vertical bar represents the average cost for a provider, sorted from highest to lowest average cost Bringing physicians together for a healthier Ohio
Ohio’s Episode Timeline
How To Access Your Report View Notification of new episode report Determine list of episode reports to view Open individual reports Download and save episode report http://www.medicaid.ohio.gov/Portals/0/Providers/P aymentInnovation/Access-Your-Report-FFS-2015- 02.pdf
How To Read Your Report Summary Performance Quality Cost Types http://www.medicaid.ohio.gov/Portals/0/Providers/Pay mentInnovation/HowtoReadYourReport.pdf
State Payment Reform Resources Office of Health Transformation: http://www.healthtransformation.ohio.gov/currentiniti atives/payforvalue.aspx Medicaid: http://medicaid.ohio.gov/PROVIDERS/PaymentInnovati on.aspx *Add footers & “Exhibit” references 22