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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
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Agenda History Comprehensive Care for Joint Replacement
Targets Impact of Care Path Data Flow Reconciliation Cardiac Bundles Oncology Care Model
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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.
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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
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Reconciliation
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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
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Targets
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Inclusions/Exclusions
Construction Data Source Inclusions/Exclusions Prorate Trend Winsorize Low Volume adjustments Target
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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
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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*
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Quality Performance Incentives
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Care Pathway
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Discharge disposition - 470 Non-Fracture
2014 SAF
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Impact on Total Spend – 470 Non-Fracture
2014 SAF
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How are other provider types paid?
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Data Flow
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Initial Data Feed
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Cardiac Bundles
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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
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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
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Price DRG – AMI Anchor DRG
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Hospital Attribution in Chained Admissions
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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”
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Questions ?
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