Maryland’s Medicare Waiver What is it? How do we fit? Gayle Olano Hurt April 21, 2015 CMSA of the Chesapeake Annual Conference

Objectives Understand the frame work for Maryland's Medicare waiver. Identify the key pay for performance components of the waiver proposal Visualize how case management can play a role in successful achievement of the wavier proposals goals

Setting the Stage Medicare Waiver (1977) Exempt from Inpatient and Outpatient Prospective Payment Systems (IPPS & OPPS) Meet specific criteria (e.g., cost containment) o Payment per admission Flexibility to set our own model & rates o All payer model o Health Services Cost Review Commission (HSCRC) Maryland - only state remaining

Challenges Challenges in this new Era of payment reform Meeting the waiver test o Rising hospital costs Value o Cost containment o What about quality of care? Integration and care coordination o $ Incentive on admissions not integration

CMS P4R and P4P HHCAHPS HHQR IQR,OQR, IPFQR VBP/HCAHPS (P4P) Readmissions (P4P) HACs (P4P) Meaningful Use ACUTE CARE HOSPITALS (7%+) MEDICAL GROUPS (6+%) Meaningful Use PQRS / CGCAHPS Physician VM (P4P) HOME HEALTH (2%) OQR HOSPITAL OUTPATIENT (2%) ICHCAHPS ESRD-QIP (P4P) DIALYSIS CENTERS (2%) Hospice CAHPS HQR HOSPICE (2%) LTCHQR NHCAHPS SNFQR (2019) SKILLED NURSING (2%) IRFQR LONG-TERM CARE (2%) REHAB HOSPITALS (2%) IPFQR INPATIENT PSYCHIATRIC FACILITY (2%) Performance Evaluation QBR ARR (& PAU) PPCs Performance Evaluation

Beyond CMS

Reimbursement Model? Value and the reimbursement model Value based payments FFS  Integrated o Accountable Care Organizations o Patient Centered Medical Homes o Bundled payments o Shared savings Fit within context of Maryland Medicare Waiver?

Value

New Waiver 5 year demonstration Federal Triple Aim Better Care Healthy People/Communities Affordable Care

Framework

Source: Maryland Hospital Association

Key Components Quality Based Revenue (2017) Healthcare Acquired Conditions (MHAC/PPC) Clinical Process HCAHPS Outcomes Efficiency

Key Components Quality Based Revenue (2017) Healthcare Acquired Conditions (MHAC/PPC) Clinical Process HCAHPS Outcomes Efficiency

Key Components Admission-Readmission Reduction (ARR) o 30 day all cause < national by end of 2018 o One example calculation New Concept: Potentially Avoidable Utilization o 30 day all cause o Revisits include inpatient, *observation, & *ER

Case Management What are the goals and purposes? Improve quality Control costs Coordination & Care Access Case Management functions* Assess Enable Facilitate Evaluate /Monitor *(Abbreviated from Moore 1990 model)

Case Management Case Management functions Assess Enable Facilitate Evaluate /Monitor (Abbreviated from Moore 1990 model)

Case Management Impact on payment based reimbursement? Outcomes measures Efficiency measures Readmission reduction Potentially avoidable utilization

Discussion / Q&A