1. Overview of CMS Bundling Programs Kelly C
Overview of CMS Bundling Programs Kelly C. Price Vice President & Chief of Healthcare Data Analytics DataGen, a HANYS Solutions Company

2. Agenda History Comprehensive Care for Joint Replacement
Targets
Impact of Care Path
Data Flow
Reconciliation
Cardiac Bundles
Oncology Care Model

3. The Evolution of Medicare Bundled Payment
ACE
BPCI
CJR
OCM
CAD
2009
Medicare Acute Care Episode Demonstration Program
2013
Medicare Bundled Payments for Care Improvement Demonstration Program
2016
Medicare Comprehensive Care for Joint Replacements Pilot Program
Medicare Oncology Care Model Demonstration Program
2017
Medicare Episodes of Care for PCI and CABG
While the notion of bundling payments for episodes of care isn’t new, CMS bundling initiatives continue to evolve.
Simplifying and organizing the complex policy and data component of these programs is challenging and requires specialized expertise to be successful.

4. Issues Data delivery Wage adjustments Conveners
Deaths within the episode
Inclusion/ Exclusion of capital
Wage adjustments
Conveners
Data delivery
Physician role
Inclusion of reconciliation/ repayments

5. Reconciliation

6. Reconciliation
DRG
Performance Period Episode Count
(a)
Performance Period Episode Target $
(b)
Total Performance Target $
(a*b)
Total Actual Performance $
(c)
Reconciliation Amount $
([a*b]-c)
470 w/o fracture
100
$24,000
$2,400,000
$2,200,000
$200,000
469 w/o fracture 10
$40,000
$400,000
$550,000
-$150,000
Hospital A Total
110
$24,455
$2,800,000
$2,750,000
$50,000
First reconciliation will take place 3 months after the end of the first performance year.
First reconciliation will be revised 12 months later to ensure all claims run-out is captured
Same process for years 2 through 5
Retrospective Reconciliation process compares a hospital’s actual episode payment performance to its target prices
-2nd reconciliation period timeframe: CMS would calculate the prior performance year’s episode spending a second time to account for final claims run-out (2 mos after end of performance yr- claims submitted by March 1 of each year), as well as overlap with other models
-reconciliation process would occur 6 mos after the end of the prior performance yr
-the amount from this calculation, if different from zero, would be applied to the NPRA for the subsequent performance year in order to determine the amount of the payment Medicare would make to the hospital or the hospital’s repayment amount
Reconciliation payments to hosp or repayments from a hospital would be made through the MAC – this is similar to BPCI Model 2

7. Targets

8. Inclusions/Exclusions
Construction
Data Source
Inclusions/Exclusions
Prorate
Trend
Winsorize
Low Volume adjustments
Target

9. Changes over time
Discount increased due to the change in the quality standards where more hospitals would meet the standards and therefore may qualify for a reconciliation payment and for a different effective discount if it meets quality performance

10. Rebasing Are you changing faster than the region?
Changes made by participants in PY 1 will impact targets for PY 3-5
Are you changing faster than the region?
Exclusion of reconciliation payments to and repayments from hospital*

11. Quality Performance Incentives

12. Care Pathway

13. Discharge disposition - 470 Non-Fracture
2014 SAF

14. Impact on Total Spend – 470 Non-Fracture
2014 SAF

15. How are other provider types paid?

16. Data Flow

17. Initial Data Feed

18. Cardiac Bundles

19. EPM Overview Mandatory Modifies CJR to align with EPM
All hospitals in selected MSAs must participate
Few exclusions (CAHs and BPCI participants)
Surgical Hip/femur Fracture (SHFFT) - DRGs
Cardiac
AMI DRGs
PCI DRGs with AMI diagnosis
CABG DRGs
Intensive Cardiac Rehab incentive program (will not be covered today)
Modifies CJR to align with EPM
Effective July 1, 2017
4.5 years (July 1, December 31, 2021)
Comments due to CMS October 3

20. EPM Overview (con’t) Bundled payments Hospitals “own” the bundles
DRG based (with a twist):
SHFFT
AMI/PCI
CABG
Episodes/bundles include initial inpatient acute stay plus all Medicare Part A and Part B covered services for 90 days post-discharge
Some exceptions for unrelated services/diagnoses
All providers continue to receive FFS payments
FFS payments are retrospectively reconciled to targets
Hospitals “own” the bundles
At risk for Medicare spending in excess of targets
Rewarded for Medicare spending below targets
Quality metrics must be met
Gainsharing with physicians and partner providers is allowed
Qualifies as an APM under MACRA

21. Price DRG – AMI Anchor DRG

22. Hospital Attribution in Chained Admissions

23. Target Stratification – Hospitals without PCI services disadvantaged
Only 1% of PCI episodes include a readmission for CABG in the post-discharge period
Expected post-discharge spend would be equal
total spend for Hospital A higher by $6,300 = loss compared to “target”

24. Questions ?