New Models of Care and Payment to Drive - PowerPoint Presentation

Slide1

New Models of Care and Payment to Drive Health Care Quality

Darren DeWalt, MD, MPH

Director, Learning and Diffusion Group

Center for Medicare and Medicaid Innovation

January 2016Slide2

Better.

Smarter.

Healthier.

“So we will continue to work across sectors and across the aisle for the goals we share:

better care, smarter spending, and healthier people

.”Slide3

Overview

CMS Innovation Center and Early Results

Learning Systems to Support Success

Delivery System Reform and Our GoalsSlide4

CMS support of health care Delivery System Reform will result in better care, smarter s

pending, and healthier

p

eople

Key characteristics

Producer-centered

Incentives for volume

Unsustainable

Fragmented Care

Systems and Policies

Fee-For-Service Payment Systems

Key characteristics

Patient-centered

Incentives for outcomes

Sustainable

Coordinated care

Systems and Policies

Value-based purchasing

Accountable Care Organizations

Episode-based payments

Medical

HomesQuality/cost transparency

Public and Private sectors

Evolving future state

Historical stateSlide5

Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system.

Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

}

“

{

Pay

Providers

Deliver

Care

Distribute

Information

FOCUS AREASSlide6

Enhanced Framework from Learning and Action NetworkSlide7

During January 2015, HHS announced goals for value-based payments within the Medicare FFS systemSlide8

2016

30%

85%

2018

50%

90%

Target

percentage of

payments

in

‘FFS

linked to

quality’

and

‘alternative

payment

models’ by

2016 and 2018

2014

~20%

>80%2011

0%~70%GoalsHistorical PerformanceAll Medicare FFS (Categories 1-4)FFS linked to quality (Categories 2-4)Alternative payment models (Categories 3-4)Slide9

LAN Work Group Goals for Payment ReformSlide10

MACRA moves us closer to meeting these goals…

2016

2018

New HHS Goals:

30%

85%

5

0%

90%

The new Merit-based Incentive Payment System

helps to link

fee-for-service payments

to quality and value.

The law also

provides incentives for

participation in Alternative Payment Models

in general and bonus payments to those in the most highly advanced APMs

0%

All

Medicare fee-for-service (FFS) payments (Categories 1-4)

Medicare

FFS

payments linked to quality and value (Categories

2

-4)

Medicare payments linked to quality and value

via APMs

(Categories 3-4)

Medicare

Payments to those in the most highly advanced APMs under MACRASlide11

How much can the Merit Based Incentive Payments System (MIPS) adjust payments?

Based on the MIPS

composite performance score

, physicians and practitioners will receive positive, negative, or neutral adjustments

up to

the percentages below.

MIPS adjustments are

budget neutral

. A

scaling factor

may be applied to upward adjustments to make total

upward and downward adjustments

equal

.

MAXIMUM

Adjustments

Adjustment to provider’s base rate of Medicare Part B payment

Merit-Based Incentive Payment System

(MIPS)

4%

5%7%9% 2019 2020 2021 2022 onward-4%-5%-7%

-9%Slide12

CMS Innovation Center and Early

Results

Learning Systems to Support Success

Delivery System Reform and Our GoalsSlide13

The CMS Innovation Center was created by the Affordable Care Act to develop, test, and implement new payment and delivery models

“The

purpose of the [Center] is to test innovative payment and service delivery models to

reduce program expenditures…while preserving or enhancing the quality of care

furnished to individuals under such

titles”

Section 3021 of Affordable Care Act

Three scenarios for success

Quality improves; cost neutral

Quality neutral; cost reduced

Quality improves; cost reduced (best case)

If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking Slide14

The Innovation Center portfolio aligns with delivery system reform focus areas

Focus Areas

CMS Innovation Center Portfolio*

Deliver Care

Learning and Diffusion

Partnership for Patients

Transforming Clinical Practice

Community-Based Care Transitions

Health Care Innovation Awards

Accountable Health Communities

State Innovation Models Initiative

SIM Round 1

SIM Round 2

Maryland All-Payer Model

Million Hearts Cardiovascular Risk Reduction Model

Distribute Information

Health Care Payment Learning and Action Network

Information to providers in CMMI models

Shared decision-making required by many models

Pay Providers

Accountable Care

Pioneer ACO ModelMedicare Shared Savings Program (housed in Center for Medicare)Advance Payment ACO ModelComprehensive ERSD Care InitiativeNext Generation ACOPrimary Care TransformationComprehensive Primary Care Initiative (CPC)Multi-Payer Advanced Primary Care Practice (MAPCP) DemonstrationIndependence at Home Demonstration Graduate Nurse Education DemonstrationHome Health Value Based PurchasingMedicare Care Choices

Bundled payment models

Bundled Payment for Care Improvement Models 1-4Oncology Care ModelComprehensive Care for Joint ReplacementInitiatives Focused on the Medicaid Medicaid Incentives for Prevention of Chronic DiseasesStrong Start InitiativeMedicaid Innovation Accelerator ProgramDual Eligible (Medicare-Medicaid Enrollees)Financial Alignment InitiativeInitiative to Reduce Avoidable Hospitalizations among Nursing Facility ResidentsMedicare Advantage (Part C) and Part D

Medicare Advantage Value-Based Insurance Design model

Part D Enhanced Medication Therapy Management

Test and expand alternative payment models

Support providers and states to improve the delivery of care

Increase information available for effective informed decision-making by consumers and providers

* Many CMMI programs test innovations across multiple focus areasSlide15

Accountable Care Organizations: Participation in Medicare ACOs growing rapidly

477 ACOs

have been established in the MSSP, Pioneer ACO, Next Generation ACO and Comprehensive ESRD Care Model programs*

This includes

121 new ACOS

in 2016 of which 64 are risk-bearing covering

8.9 million assigned beneficiaries

across 49 states & Washington, DC

ACO-Assigned Beneficiaries by

County**

* January 2016

** Last updated April 2015Slide16

Medicare Shared Savings Program: Results to date

1

2013 figures include both 2012 and 2013 savings / loss generated for some ACOs that started mid-year in 2012 (these were the first ACOs in the program)

Financial Results

In

2014:

92 ACOs (28%)

held spending $806 million below their targets and earned performance payments of more than $341 million

An additional 89 ACOs reduced health care costs compared to their benchmark, but did not meet the minimum savings threshold.

ACOs with more experience in the program were more likely to generate shared savings: 37 percent of 2012 starters, compared to 27 percent of those that entered in 2013, and 19 percent of those that entered in 2014

.

In 2013

1

:

58 ACOs (26%)

held spending $705 million below their targets and earned performance payments of more than $315 million

Quality Results

ACOs that reported in both 2013 and 2014

improved

average performance on 27 of 33 quality measuresSlide17

Pioneer ACOs were designed for

organizations with experience in coordinated care

and ACO-like contracts

Pioneer ACOs

generated savings for

three years

in a row

Total savings

of $92 million in PY1, $96 million in PY2, and $120 million in PY3‡

Average savings per ACO

increased

from $2.7 million in PY1 to $4.2 million in

PY2

to $6.0 million in PY3

‡Pioneer ACOs showed

improved quality outcomesMean quality score increased

from 72% to 85% to 87% from 2012–2014 Average performance score improved

in 28 of 33 (85%) quality measures in PY3Elements of the Pioneer ACO have been incorporated into track 3 of the MSSP ACOPioneer ACOs meet requirement for expansion after two years and continued to generate savings in performance year 319 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiariesDuration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years‡ Results from actuarial analysisSlide18

Pioneer

ACO: Actuarial Results to date

120

2014

82

62

-9

-15

2013

96

66

63

-11

-23

2012

92

77

64

-3

-47

How to read this graph – in 2014, for example:

Among 15 ACOs that generated savings, $82 M of the total savings was retained by CMS, while $62 was shared with 11 ACOs in the form of shared savings payments

Among 5 ACOs that generated losses, $15 M of the total losses was absorbed by CMS, while $9 M was paid back to CMS by 3 ACOs

Total program savings was $120 M

18 ACOS generated savings (14 received payment)

14 generated losses (1 owed CMS)

1

14 ACOS generated savings (11 received payment)

9 generated losses (6 owed CMS)

15 ACOS generated savings (11 received payment)

5 generated losses (3 owed CMS)

Savings retained by CMS

Shared savings (paid to ACO from CMS)

Losses absorbed by CMS

Shared losses (paid to CMS from ACO)

Pioneer ACO Savings / Loss Results by Year

Total Pioneer ACO model savings

has increased from $92 million in 2012 to $96 million in 2013 to $120 million in 2014 (average savings per ACO increased from $2.7 million to $4.2 million to $6.0 million)

1 D

etermination of whether an ACO with savings or loss will receive a payment from CMS or owe CMS is dependent on exceeding minimum financial threshold, risk track (some ACOs elected one-sided risk track offered only in PY1), quality scoreSlide19

Comprehensive Primary Care (CPC) is showing early but positive results

7 regions (AR, OR, NJ, CO, OK, OH/KY, NY) encompassing 31

payers

, nearly 500 practices, and

approximately

2.5

million multi-payer patients

Duration of model test: Oct

2012 –

Dec 2016

CMS convenes Medicaid and commercial payers to support primary care practice transformation through enhanced, non-visit-based payments, data feedback, and learning systems

$14 or 2%* reduction

part A and B expenditure

in year 1 among all 7 CPC regions

Reductions appear to be driven by initiative-wide impacts on hospitalizations, ED visits, and unplanned 30-day readmissions

* Reductions relative to a matched comparison group and do not include the care management fees (~$20

pbpm

)Slide20

CPC shared savings results for 2014 (performance year 2) varied

Gross savings:

1.5%

Gross losses:

3.8%

Gross losses:

0.7%

Gross savings:

1.4%

Gross savings:

4.8%

Net savings:

2.4%

Gross savings:

1.3%

Gross savings:

0.2%

Gross lossesGross savingsNet savingsSlide21

Spotlight: Comprehensive Primary Care, SAMA Healthcare

SAMA Healthcare Services is an independent four-physician family practice located located in El Dorado, a town in rural southeast Arkansas

“A lot of the things we’re doing now are things we wanted to do in the past…

We needed the front-end investment

of start-up money to develop our teams and our processes”

-Practice Administrator

S

ervices made possible by CPC investment

Care management

Each

Care Team

consists of a doctor, a nurse practitioner, a care coordinator, and three nurses

T

eams drive

proactive preventive care

for approximately 19,000 patients

Teams use

Allscripts

’

Clinical Decision Support

feature to alert the team to missing screenings and lab work

Risk stratificationThe practice implemented the AAFP six-level risk stratification toolNurses mark records before the visit and physicians confirm stratification during the patient encounterSlide22

Partnership for Patients contributes to quality improvements

Ventilator-Associated Pneumonia

Early Elective Delivery

Central

Line-Associated Blood Stream Infections

Venous thromboembolic complications

Re-admissions

Leading Indicators, change from 2010 to 2013

62.4% ↓

70.4% ↓

12.3% ↓

14.2% ↓

7.3% ↓

Data shows from 2010 to 2014…

87,000

2.1 million

PATIENT HARM EVENTS AVOIDED

$20 billion

IN SAVINGSSlide23

Medicare all-cause, 30-day hospital readmission rate is declining

Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit

Readmission RateSlide24

CMS Innovation Center and Early Results

Learning Systems to Support Success

Delivery System Reform and Our GoalsSlide25

Learning Systems at ScaleTraditional tests of new payment models include new payment rules and technical assistance to understand the rulesEvaluation is conducted to assess whether new payment or care delivery model “worked”At CMMI, we wish to increase the chance of success by creating learning systems to support model testsA learning system is a systematic improvement framework to understand change across a mix of health systems

JAMA 314(20):2131-2. 2015 Slide26

Learning Systems Working WellEngaged and activated participants from delivery systemCMS engaged and learning with the participantsTheory/framework for learningFrequent and timely data on process and outcomesLearning events that lead to changes in the delivery of careUser friendly strategies for sharing and discussing promising practicesRelentless focus on outcomes

“Aims build systems and systems get results”Slide27

1. Establish Clear AimsExpectations of the model testAll models have cost and quality aimsCPC Example: “Better health and better care for patients and families and lower total cost of care” Comprehensive Primary CareCost measured through CMS claims data

Care measured through EHR-based and claims-based performance measures and surveys of patient experienceSlide28

2. Develop an Explicit Theory of ChangeWe use the driver diagram (action-oriented logic model)Created at initial planning, but updated as we learn how the model worksSlide29

3. Create the Context Necessary for a Test of the ModelConsideration of new partnerships between and within public and private entitiesCooperation between payers and providersNew payment arrangements or regulatory waiversAccess to dataCPC example

Multipayer

participation—critical for practices to have large enough fraction of patients covered by enhanced payment

Decision to make shared savings payments at the regional level to get sample size that yields stable estimatesSlide30

4. Develop the Change StrategyFlows from the theory of how the model worksIdentify change concepts and tacticsExpect the change strategy to evolve over time

CPC Driver 1.2: Planned Care and Population HealthSlide31

5. Test the ChangesAlmost all improvement efforts in health care reveal important differences between the proposed test and what actually gets tested and adopted in practiceWe design our models with the intent to make incremental changes as we goIn CPCUnderstand what elements are harder and easier for practices

What support do they need to master new capabilities?

What new strategies are needed? (EHR affinity group)Slide32

6. Measure Progress Toward AimCMMI models assess outcomes, processes, unintended consequencesTry to use measures that are part of monitoring and evaluationIn CPCTracking milestones that related to comprehensive primary care functions (process)

Assess patient experience

(process and unintended consequences)

Assess quarterly claims data

(outcome)

Assess clinical quality measures (outcome)Slide33

7. Plan for SpreadUse of successful or promising changes between model test sites (role of current learning systems)Create learning communitiesPackage and make available what is working (change package)Dissemination of successful or promising changes beyond model test sites

Consider strategies to help model participants if the model can expand under current law

Design with the end in mind and use the model test to inform expansion strategySlide34

Summary of Large Scale Learning SystemsEstablish clear aimsDevelop an explicit theory of changeCreate the context necessary for a test of the modelDevelop the change strategy

Test the changes

Measure progress toward the aim

Plan for spread

Large-scale PDSA testing cyclesSlide35

Challenges for CMMI Learning SystemsEngaging model participants in the learning systemRight sizing the data collection to inform the learning system but not to burden the participantsCompetition among model participantsBalancing cost / benefit – how much is enough investment in the learning system

?

Role of CMS as a regulator

Complicated nature of participant relationshipsSlide36

CMS Invests in Large Scale System ChangeSlide37

Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformationThe model will support over 140,000

clinician practices

over the next four years

to

improve on quality and enter alternative payment models

Phases of Transformation

Two network systems

Practice Transformation Networks

: peer-based learning networks designed to coach, mentor, and assist

Support and Alignment Networks

: provides a system for workforce development utilizing professional associations and public-private partnershipsSlide38

Transforming Clinical Practice Goals

1

2

3

4

5

6Slide39

Practice Transformation in Action

This technical assistance would enable large-scale transformation of more than

140,000 clinicians‘ and

their practices to deliver

better care and result in better health outcomes at lower costs

.

Transforming Clinical Practice would employ a

three-prong approach

to national technical assistance.Slide40

We are focused on:Implementation of Models

Monitoring & Optimization of Results

Evaluation and Scaling

Integrating Innovation across CMS

Portfolio analysis and launch new models to round out portfolio

Innovation

Center – 2016

Looking ForwardSlide41

Disclaimers

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.