Mary Carr, RN MPH, V.P. for Regulatory Affairs, National Association of Home Care & Hospice Home health Regulatory Roundup ---- Part 2

FOCUS Value-Based Purchasing Pilot program IMPACT Act Joint Replacement Bundling

Value Based Purchase Pilot HHS Goal 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, 50 percent of payments to these models by the end of percent of all FFS Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Value Based Purchasing and the Hospital Readmissions Reduction Programs

Value-Based Purchasing Pilot Earlier comments to CMS Concern on the magnitude of the adjustment Encouragement of pay for performance and pay for reporting Measures: exclude 5-Star system, HHCAPS’ re- hospitalizations, OASIS measures Support risk adjustment strategy, voluntary participation

Value-Based Purchasing Pilot Proposed states: MA, MD, NC, FL, WA, AZ, IA, NE, TN – 9 regions – Randomized selection w/in each region – Subject to change Factors considered in setting up regions HHA size – Utilization levels – Rural – Dual-eligibles – Proportion of minorities

Value-Based Purchasing Pilot “smaller-volume”—exempt from HHCAPS “larger-volume”—HHCAPS participant

Value-Based Purchasing Pilot Payment Adjustment Timeline – 5 performance years beginning in > 2018 payment adjustment (5%) 2017 > 2019 payment adjustment (5%) 2018 > 2020 payment adjustment (6%) 2019 > 2021 payment adjustment (8%) 2020 > 2022 payment adjustment (8%) – May modify schedule beginning in 2019 with more frequent adjustments

Value-Based Purchasing Pilot Measures – 10 Process; 15 Outcome; 4 New Measures – OASIS; Claims; HHCAPS Principles: – Broad set to capture HHA complexities – Flexibility to include IMPACT Act proposed PAC measures – Develop second-generation measures of outcomes, health and functional status, shared decisionmaking and patient activation – Balance of process, outcome, and patient experience – Advance ability to measure cost and value – Measures on appropriateness and overuse – Promote infrastructure investments

Value-Based Purchasing Pilot: Measures Outcome – Improvement in ambulation-locomotion (OASIS) – Improvement in bed transferring – Improvement in Bathing – Improvement in Dyspnea – Discharged to community – Improvement in pain interfering with activity – Improvement in oral medication management – Prior functioning ADL/IADL – Acute care hospitalization (unplanned w/in 60 days; during first 30 days) (Claims) – Emergency Department use w/o hospitalization – Care of Patients (CAHPS) – Communication between providers and patients (CAHPS) – Specific care Issues (CAHPS) – Overall rating (CAHPS) – Willingness to recommend the agency (CAHPS)

Value-Based Purchasing Pilot: Measures Process Depression assessment conducted (OASIS) Influenza vaccine data collection Influenza immunization received Pneumococcal vaccine received Reason Pneumococcal vaccine not received Drug education Timely initiation of care Care management: Types and sources of assistance Pressure ulcer prevention and care Multifactor fall risk assessment /pts who can ambulate

Value-Based Purchasing Pilot: Measures New Measures: HHA reporting through portal Influenza vaccination of HH staff Herpes zoster )shingles) vaccines for HHA patients Advanced Care planning Adverse event for improper medication

Value-Based Purchasing Pilot: Scoring Quarterly assessment Total Performance Score (TPS): higher of achievement or performance score in each measure All Outcome and Process measures have equal weight and account for 90% of TPS New Measure reported accounts for 10% and each has equal weight Points only for “applicable measures” (20 episodes per year) – 0 to 10 points on each Outcome and Process measure – 10 or 0 points on New Measures (report vs. no report)

Value-Based Purchasing Pilot: Scoring “Achievement threshold”: median of all HHA performance in baseline period “benchmark”: mean of top decile of all HHA performance in baseline period State specific; separate “smaller” and “larger” HHAs Each measure is separately scored

Value-Based Purchasing Pilot: Scoring Achievement scoring – HHA with performance equal to or higher than benchmark receives 10 points – HHA with performance equal to or greater than achievement threshold receives 1-9 points based on formula: 9 X (HHA performance score-achievement threshold) divided by (benchmark-achievement threshold) – HHA with performance less than achievement threshold receives 0 points

Value-Based Purchasing Pilot: Scoring Improvement scoring – HHA with performance equal to or higher than benchmark receives 10 points – HHA with performance greater than its baseline period receives 1-9 points based on formula: 10 X (HHA performance period score-HHA baseline period score) divided by (benchmark-HHA baseline period score) – HHA with performance equal or less than baseline period score receives 0 points

Value-Based Purchasing Pilot: Scoring Total Performance Score (TPS) Use only those measures out of the 25 with 20 or more episodes Use higher of improvement or achievement score Divide total earned points by total possible points multiplied by 90 Add New Measure points (points earned/possible points X 10)

Value-Based Purchasing Pilot: Preview Opportunity to review quarterly quality reports – 10 days to request recalculation – July 2016 first report Opportunity to review TPS and payment adjustment calculations – August 1, 2017 first notification – 10 days to request recalculation – Final report no later than November 1, 2017

VALUE BASED PURCHASING PILOT: IMPACT 10% of HHAs would experience a -5% or greater reduction under the 8% withhold level ( )

NAHC ADVOCACY PLAN Contest Value-Based Purchasing Pilot design 5-8% at risk is unsustainable Lost resources prevent performance improvement Use of public comment process by all stakeholders Secure beneficiary advocate support Congressional intervention

HHQRP - IMPACT ACT Passed Sept 2014 Requires PAC provider report standardized assessment data and quality, resource, and other measures HHAs, SNFs, IRFs, and LTCHs Time line Quality measure on domains between Assessment data HHA 2019; others 2018

IMPACT ACT Domains (HH) Functional and cognitive status and changes in functional and cognitive status (2019) Skin integrity and changes (2017) Medication reconciliation (2017) Incident of falls (2019) Transition of care (2019) Resource use measures, including total estimated Medicare spending per beneficiary(2017) Discharge to community (2017) Measures to reflect all-condition risk- adjusted potentially preventable hospital readmission rates (2017)

IMPACT ACT Standardized Data Assessment Data Categories Functional status Cognitive function and mental status Special services, treatments, and interventions Medical conditions and co-morbidities Impairments Other categories required by the Secretary HH 2019

Quality Measures (IMPACT) Functional status, cognitive function, and changes in function and cognitive function Percent of patients/residents with an admission and discharge functional assessment and a care plan that addresses function Skin integrity and changes in skin integrity Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678 ) Incidence of major falls Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

IMPACT ACT 2016 HH Proposed rule included: Skin integrity and changes in skin integrity Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678 ) Uses OASIS C-1 data set items M01308 and M01309 Feedback on this measure and future measures to implement the IMPACT Act

CMS measures under consideration (MUC) list Measure Application Partnership(MAP)-National Quality Forum (NQF) Guides HHS in measure selection for Federal programs Public - private partnership IMPACT ACT

CMS Measure Management web page Call for Measures Public comments on measures Technical Expert Panel nominations Assessment-Instruments/MMS/index.html IMPACT ACT

NQF Calendar of activities: MAP Coordinating committee project page: ating_Committee.aspx MAP PAC-LTC workgroup project page: Acute_CareLong-Term_Care_Workgroup.aspx CMS’s Pre-Rulemaking page: Assessment-Instruments/QualityMeasures/Pre-Rule- Making.html

IMPACT Act Open Door Forums (ODFs): SNF, LTC: October 29 and December 1 HH, Hospice, DME: November 4 and December 16 Special Open Door Forum (SODF): Understanding The IMPACT Act- Patient and Family Focused for Informed Decision Making. Wednesday, October 28, 2015, from 1:00 p.m. –3:00p.m. Eastern Time CMS Quality Conference Presentation: December 1 –3, 2015 (planned) CMS National Training Program Partner Update Webinar: January 2016 (planned)

CMS Proposed Joint Replacement Bundling CMS proposes to “bundle” payment for joint replacement services under 1115A waiver MS-DRG 469 (Major joint replacement or reattachment of lower extremity with Major Complications or Comorbidities (MCC)) or MS-DRG 470 (Major joint replacement or reattachment of lower extremity without MCC). 75 geographic areas Mandatory participation with some exclusions Includes hospitalization plus all Part A and Part B related services for 90 days post-discharge Begins January 1, 2016; 5 performance years

CMS Proposed Joint Replacement Bundling Hospital as the risk bearing participant Encourages, but does not dictate care and financial integration Retains patient freedom of choice of providers No direct care control Reconciliation process on shared savings payment or overpayment recovery Phase-in with no recovery until year 2 Certain rule waivers 3-day hospitalization pre-SNF Post-discharge home visits where no home health coverage Telehealth site of service (permits service in home) Rejects a “homebound” waiver