PYA Principal Martie Ross and Senior Consultant Aaron Elias conducted a session at the Association of Healthcare Internal Auditors (AHIA) 36th Annual Conference. The presentation was titled: “The Times, They Are A- Changin’: Alternative Payment Models Panel Presentation.”
Areas of focus included:
•Discussing new payment models available to providers, including the Merit-Based Incentive Payment System and Advanced Alternative Payment Models.
•Exploring CMS’ progress toward goals related to payment reform.
•Understanding alternative payment models and pay-for-performance programs—which components require auditing and recommendations for potential auditing processes.
4. Page 3
A Movement Is Underway
Committed to having
75% of respective
businesses operating
under value-based
payments by 2020
5. Page 4
APM Framework
FEE-FOR-SERVICE
(FFS) PAYMENTS
POPULATION-BASED
APMs
ADJUSTED FFS
PAYMENTS
APMs INCORPORATING
FFS PAYMENTS
$
$
Bank
A Pay for
Reporting
B Pay for
Performance
C Foundational
Payments for
Infrastructure
and Operations
A APMs with Upside
Gainsharing
B APMs with Upside
Gainsharing /
Downside Risk
A Condition-Specific
Population-
Based
Payments
B Direct Primary Care
C Comprehensive
Population-
Based
Payments
A Traditional FFS
Source: Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework Final Whitepaper (2017)
6. Page 5
Payment Reform in Action
Source: Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework Final Whitepaper (2017)
7. Page 6
Payment Reform in Action
One-quarter of commercial plan payments
now flow through APMs.*
* Health Care Payment Learning & Action Network 2016 Commercial Payer Survey (respondents represent over 128 million covered lives, or
nearly 44% of the combined commercial, Medicare Advantage, and Medicaid markets)
8. Page 7
FFS Care Management
Rewards the monitoring and maintenance of care plans
Other Examples:
Advance Care Planning
Behavioral Health
Integration
Chronic Care Management
Incentive: Payment for non-face-to-
face time caring for
patients
Structure: Expanded CCM
program in the 2017
Medicare Physician
Fee Schedule
Separate payment for
care plan development
Transitional Care Management
Incentive: Payment to smooth
transitions between
providers
Structure: Providers must make
contact with
beneficiaries within 7 or
14 days of discharge
9. Page 8
Spotlight: CPC+
Comprehensive Primary Care Plus
Key Features
Multi-payer
PBPM care management fee to
support infrastructure development
PBPM refundable performance
payment
Adjusted E/M payments (Track 2)
2,866 primary care practices
across 18 selected regions (by
January 1, 2018)
Includes:
Care Management Fees
Performance-Based Incentive
Payments
Care
Management
Fee (PBPM)
Performance-
Based Incentive
Payment (PBPM)
Payment
Structure
Redesign
Objective
Support augmented
staffing and training
for delivering
comprehensive
primary care
Reward practice
performance on
utilization and quality
of care
Reduce
dependence on
visit-based fee-for-
service to offer
flexibility in care
setting
Track 1 $15 average $2.50 opportunity
N/A
(Standard FFS)
Track 2
$28 average;
including $100 to
support patients with
complex needs
$4.00 opportunity
Reduce FFS with
prospective
“Comprehensive
Primary Care
Payment” (CPCP)
10. Page 9
Pay for Performance
9
Pay for reporting
Bonus payments based on quality scores
Upward/downward adjustments to fee schedule
payments
11. Page 10
Spotlight: MIPS
Merit-Based Incentive Payment System is the primary pay-for-performance
program
Quality Cost
Improvement
Activities
Advancing Care
Information
−Report quality
measures
−Scored based on
relative
performance
−“Practice
Transformation”
−Drive patient-
centered care
−Promote expanded
adoption of EHRs
−Improve utilization
and sharing of
electronic health
information
−Drive efficient care
−Providers forced to
accept risk
60%
0%
15%
25%
60%
0%
15%
25% 30%
30%
15%
25%
2017 Performance Year 2018 Performance Year 2019 Performance Year
Impacts 2019 Payments Impacts 2020 Payments Impacts 2021 Payments
12. Page 11
Shared Savings Arrangements
Rewards providers for working together to reduce payer’s cost
for an attributed population
Incentive: Portion of the savings realized, in addition to
fee-for-service payments
Structure: One- or two-sided models depending on risk
tolerance
Examples: Medicare Shared Savings Program
Next generation ACOs
Commercial payer programs
13. Page 12
Spotlight: MSSP
Medicare Shared Savings Program
▪ Rewards ACOs that lower
growth in healthcare costs
while meeting performance
standards
Medicare pays providers under
the Medicare Fee-For-Service
payment systems
ACO spending measured against
a historical financial benchmark
Shared savings are subjected to
adjustment based on quality
Tracks 1+, 2, and 3 count as
Advanced APMs under QPP
Track 1
One-sided risk
Sharing rate: Up to 50%
Performance payment limit: 10%
Track
1+
Two-sided risk
Sharing rate: Up to 50%
Performance payment limit: 10%
Shared loss rate: Fixed 30%
Prospective beneficiary assignment
Choice of MSR/MLR
Track 2
Two-sided risk
Sharing rate: Up to 60%
Performance payment limit: 15%
Shared loss rate: 40% - 60%
Track 3
Two-sided risk
Sharing rate: Up to 70%
Performance payment limit: 20%
Shared loss rate: 40% - 75%
Prospective beneficiary assignment
14. Page 13
Spotlight: MSSP
13
MSSP Waivers
ACO Pre-Participation Wavier
ACO Participation Wavier
Shared Savings Distribution Waiver
Compliance with the Stark Law Waiver
Patient Incentive Waiver
Protect financial arrangements that further the purposes
of the MSSP from challenge under the Anti-Kickback
Statute, the Stark Law, and Civil Monetary Penalties Act
15. Page 14
Episodic (Bundled) Payments
Rewards coordination and efficiency among all providers within
a specific episode of care
Incentive: Retain overage of payment if costs are managed
below target
Structure: Payment for all services furnished during an
identified cost of care, prospective or retrospective
models depending on risk tolerance
Examples: Bundled Payment for Care Improvement
Oncology Care Model
Comprehensive Care for Joint Replacement
Episodic Payment Model
16. Page 15
Spotlight: CJR
Comprehensive Care for Joint Replacement
▪ Hospitals accountable for quality and cost for hip and
knee replacement surgeries (adding hip and femur
fractures effective January 1, 2018)
▪ Incentivizes increased coordination of care among:
Hospitals
Physicians
Post-acute care providers
▪ 90-day episode of care
▪ 67 MSAs included
17. Page 16
Spotlight: EPM
Episode Payment Model
▪ Final rule released December 20, 2016
Effective January 1, 2018
▪ New models:
Acute Myocardial Infarction (AMI)
Coronary Artery Bypass Grafting (CABG)
▪ 98 MSAs included
18. Page 17
EPM Bundle Definitions
AMI, CABG, & SHFFT
AMI CABG
Services included Part A and B services
Episode start
At admission for AMI
treatment
At admission for CABG
treatment
Episode end 90 days following hospital discharge
Payment Retrospective
MS-DRGs
280, 281, 282
Contingent:
246, 247, 248, 249, 250,
251
231, 232, 233, 234, 235,
236
19. Page 18
Example: AMI Analysis
PYA performed
analytics for AMI
episodes in
Nashville, TN market
Episodes initiated at
10 different
Nashville-area
hospitals
260 different SNFs,
outpatient facilities,
and home health
agencies
KEYFINDINGS
Among these 270 organizations, there was a wide
variation in AMI-associated costs – ranging from
$5,500 to $58,000
By far, the largest drivers of cost variations were
hospital readmissions and length of SNF stays
Among the costliest 20% of episodes, the average
was $43,200 - nearly 4 times higher than the overall
average
The overall AMI readmission rate was 27%, but the
20% highest paid episodes had a rate nearly 3 times
higher: 76%
The top quintile of highest paid episodes had SNF
costs that were 3 times higher than the overall
average
20. Page 19
Gainsharing Under Cardiac EPMs
19
Three permitted financial arrangements under a Sharing
Arrangement
Sharing a Reconciliation Payment with an EPM
Collaborator--hospitals may pay all or a portion of the
reconciliation payment for a given performance year
Sharing Internal Cost Savings with an EPM Collaborator--
hospitals may share measurable and actual cost savings
with EPM collaborators
Sharing a Repayment Obligation with an EPM
Collaborator--hospitals may pay all or a portion of the
repayment obligation to CMS
21. Page 20
Global Budgets
Rewards provider network for managing a defined patient
population within a single budget
Incentive: Reduce unnecessary and avoidable services to
remain within budget
Structure: Advance payment for network to assume full
responsibility for defined population
Examples: Comprehensive ESRD Care Model
Provider-led Medicare Advantage plans
28. Page 27
Thank You
27
Aaron Elias
Senior Consultant
PYA
aelias@pyapc.com
(319) 560-0716
Martie Ross
Principal
PYA
mross@pyapc.com
(913) 232-5145
Susan Thomas
Senior Manager
PYA
sthomas@pyapc.com
(913) 232-5145
Notas del editor
Mississippi is NOT a selected region
Only a handful of counties in MS are part of an MSA for CCJR, in the Northwest
AMI
MS-DRG 280 (Acute myocardial infarction, discharged alive with MCC),
MS-DRG 281 (Acute myocardial infarction, discharged alive with CC),
MS-DRG 282 (Acute myocardial infarction, discharged alive without CC/MCC).
Percutaneous catheter insertion including an AMI ICD-10-CM diagnosis code in the principal or secondary position on the IPPS claim
MS-DRG 246 (Percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels/stents),
MS-DRG 247 (Percutaneous cardiovascular procedures with drug-eluting stent without MCC),
MS-DRG 248 (Percutaneous cardiovascular procedures with non-drug-eluting stent with MCC or 4+ vessels/stents),
MS-DRG 249 (Percutaneous cardiovascular procedures with non-drug-eluting stent without MCC),
MS-DRG 250 Percutaneous cardiovascular procedures without coronary artery stent with MCC), and
MS-DRG 251 (Percutaneous cardiovascular procedures without coronary artery stent without MCC).
CABG
MS-DRG 231 (Coronary bypass with percutaneous transluminal coronary angioplasty (PTCA) with MCC),
MS-DRG 232 (Coronary bypass with PTCA without MCC),
MS-DRG 233 (Coronary bypass with cardiac catheterization with MCC),
MS-DRG 234 (Coronary bypass with cardiac catheterization without MCC),
MS-DRG 235 (Coronary bypass without cardiac catheterization with MCC), or
MS-DRG 236 (Coronary bypass without cardiac catheterization without MCC).
SHFFT:
MS-DRG 480 (Hip and femur procedures except major joint with major complication or comorbidity - CC),
MS-DRG 481 (Hip and femur procedures except major joint with complication or comorbidity - MCC), or
MS-DRG 482 (Hip and femur procedures except major joint without CC or MCC).