Bundled Payments for

Care Improvement

(BPCI)Opportunity

Information on the AAMC Facilitator-Convener Group and Program Update

February 21, 2014

Agenda

• Welcome

• Winter Open Period for BPCI

• BPCI Model

• Timeline for New Hospitals

• Role of the AAMC as Facilitator-Convener

• Program Parameters/Payment Model

• New AAMC Resource: Maximizing Value

• Discussion and Q&A

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BPCI Winter Open Period

• Announced Feb. 14 via Federal Register notice

• Notice available online: http://www.gpo.gov/fdsys/pkg/FR-2014-02-14/pdf/2014-03311.pdf

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BPCI is now open to

any new participants

For those of you who

would like to join a

group of peers, the

AAMC facilitator-

convener group will

also be adding new

participants

Required Process

• Documents for joining BPCI can be found here: http://innovation.cms.gov/initiatives/Bundled-Payments/Models2-4OpenPeriod.html

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If you wish to join the AAMC

facilitator-convener group,

please contact AAMC for

instructions on completing

required documents

If you wish to join as an

individual organization, you

must complete the documents

under the heading “New

Participants Open Period

Information”

Bundled Payments for Care

Improvement Initiative (BPCI)

In August 2011, CMMI invited providers to apply to test and develop four different models of bundled payments. Applications were due to CMMI in June 2012, and the first group of participants entered into the risk-bearing phase on October 1, 2013 and January 1, 2014.

• Model 1: Inpatient stay (discounted IPPS payment)

• Model 2: Inpatient stay plus post-discharge services (retrospective)

• Model 3: Post-discharge services only (retrospective)

• Model 4: Inpatient stay only (prospective)

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Episode Definition

Inpatient ProfessionalIndex Hospitalization

Index HospitalizationInpatient Professional

Post-Acute: IRF, SNF, HHA

Outpatient Professional

Beneficiary

Inclusion

Criteria

(Reason for

hospitalization

+ other)

Episode anchorEnd of Episode

Trigger MS-DRGs

Timeline

Key Date Program Milestone

April 1, 2014 If joining AAMC facilitator-convener group, submit template

letter of commitment to AAMC and intake forms to AAMC

for submission to CMMI

April 18, 2014 New Participant Intake Forms due to CMMI

July 2014 Following a preliminary review by CMMI, new hospitals (i.e.

episode initiators) will complete Data Use Agreement

documents and begin receiving monthly data from CMMI

September 2014 CMS will distribute episode packets and historical data files

to allow replication of target prices for new episodes and

Episode Initiators that are offered participation in Phase 2

November 2014 Signing of awardee agreements (as well as episode

selection, description of gainsharing and care redesign

plans)

January 1, 2015 Go-live for new hospitals

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Role of the Facilitator-Convener

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Role of the Facilitator-Convener

“A convener may submit an application in partnership with multiple providers, where the convener would participate as a facilitator. In this capacity, the convener could serve an administrative and technical assistance function for one or more designated awardees.

In this arrangement, the facilitator convener would not have an agreement with CMS, bear financial risk, or receive any payment from CMS. The facilitator convener could share in the financial risk or cost savings from increased efficiencies experienced by designated awardee(s) through contracts between the convener and the awardee(s).” CMMI 2011

The new open period allows episode initiators to come into the program without a convener, as their own convener or on their own

This decision should be based on your readiness to manage CMS episode level data, price verification decisions, episode selections decisions and care redesign strategies that improve cost and quality

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AAMC Facilitator-Convener Group

Albert Einstein Healthcare Network l Duke l NYU Langone Medical Center l Our Lady Of

The Lake Regional Medical Center (LA) l Penn State Hershey Health System l Sinai

Health System (IL) l UCSF l University Of Colorado l Vanderbilt University Medical Center

BJC HealthCare l Christiana Care Health System l Oakwood Healthcare l UMass Memorial

HealthCare l University of New Mexico

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AAMC’s Convener Role

• Data and Analytics

• AAMC partners with DataGen and Singletrack for all BPCI analytics: price verification, ongoing monthly data files, risk analysis, ad hoc projects

• Care Redesign Support

• Collaborative efforts including group meetings and webinars

• Individual AAMC support

• Intensive CMS advocacy efforts including collaboration with other conveners

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Data Vendor: DataGen

DataGen is a wholly-owned subsidiary of the Healthcare

Association of New York State (HANYS) and performs research

and analytics with a diverse staff includes policy and research

analysts, programmers, a database manager, and an

epidemiologist. All of DataGen’s staff have experience working

with claims level and hospital financial data.

For more than fifteen years, the DataGen team has modeled

and analyzed reimbursement/payment policies, quality measure

reporting, and pay-for-performance programs for HANYS and an

expanding number of other state hospital associations (45) and

national systems (7). DataGen has developed analytics and

reports for HANYS’ many quality collaboratives, and is

particularly successful at building presentation dashboards and

other forms of data visualization for its analytic work.

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Data Vendor: Singletrack

Singletrack Analytics is a healthcare consulting firm specializing in financial technology and analytics, and in bridging the interdisciplinary gap between finance and information technology that exists in many organizations.

SA works with hospital, physician provider groups, and with other consulting firms, to design data models of payment systems to allow these clients to understand the drivers of financial and operational results.

SA currently provides data analytics for ACOs and a number of Medicare bundled payment participants.

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BPCI 360Table of Contents

Index DRG Episode Count

Total Actual

Payment

Amount

Average

Actual

Payment

Amount per

Episode CV

High Outlier

Percentage

292 - Heart failure & shock w CC 245 $6,966,679 $28,435 1.05 2 %

291 - Heart failure & shock w MCC 175 $6,247,623 $35,701 0.80 1 %

470 - Major joint replacement or reattachment of lower extremity w/o MCC 170 $6,509,726 $38,293 0.41 1 %

065 - Intracranial hemorrhage or cerebral infarction w CC 105 $3,357,889 $31,980 0.64 0 %

293 - Heart failure & shock w/o CC/MCC 97 $1,722,099 $17,754 0.99 1 %

066 - Intracranial hemorrhage or cerebral infarction w/o CC/MCC 44 $1,100,092 $25,002 0.80 2 %

064 - Intracranial hemorrhage or cerebral infarction w MCC 36 $1,921,274 $53,369 0.76 6 %

235 - Coronary bypass w/o cardiac cath w MCC 18 $928,718 $51,595 0.33 0 %

233 - Coronary bypass w cardiac cath w MCC 17 $1,228,426 $72,260 0.26 0 %

236 - Coronary bypass w/o cardiac cath w/o MCC 15 $553,562 $36,904 0.25 0 %

469 - Major joint replacement or reattachment of lower extremity w MCC 12 $689,611 $57,468 0.37 0 %

234 - Coronary bypass w cardiac cath w/o MCC 11 $599,666 $54,515 0.63 9 %

062 - Acute ischemic stroke w use of thrombolytic agent w CC 5 $182,644 $36,529 0.51 0 %

232 - Coronary bypass w PTCA w/o MCC 4 $197,388 $49,347 0.05 0 %

231 - Coronary bypass w PTCA w MCC 2 $115,840 $57,920 0.04 0 %

061 - Acute ischemic stroke w use of thrombolytic agent w MCC 2 $80,348 $40,174 0.24 0 %

063 - Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC 2 $25,615 $12,807 0.03 0 %

Grand Total 960 $32,427,200 $33,778 0.79 1 %

Volume and Variation

Episode Family

Cardiac valve

Congestive heart failure

Coronary artery bypass ...

Major joint replacemen...

Index DRG

061 - Acute ischemic str...

062 - Acute ischemic str...

063 - Acute ischemic str...

064 - Intracranial hemo...

Year: Episode Index Admit...

2009 2010 2011

2012 2013 2014

2015 2016 2017

Quarter: Episode Index A...

Qtr 1 2011 Qtr 2 2011

Qtr 3 2011 Qtr 4 2011

Qtr 1 2009 Qtr 2 2009

Qtr 3 2009 Qtr 4 2009

DataGen and Singltrack’s BPCI360 model helps organizations to

assess areas of opportunity, evaluate episodes for selection, and

monitor ongoing performance

BPCI Episodes and

Payment Parameters

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BPCI Episodes

• BPCI offers participants 48 episodes to select from for participation in the program

• CMS estimates that these 48 episodes represent nearly 70% of Medicare admissions

• AAMC encourages potential participants to consider reviewing data from ALL episodes; requesting episodes is non-binding, you can add episodes quarterly and not go live with all episodes initially requested

• Once a part of the convened group, DataGen and AAMC will assist in decisions on episode selection

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• Acute myocardial infarction• AICD generator or lead• Amputation• Atherosclerosis• Back & neck except spinal fusion• Coronary artery bypass graft• Cardiac arrhythmia• Cardiac defibrillator• Cardiac valve • Cellulitis• Cervical spinal fusion• Chest pain• Combined anterior posterior spinal fusion• Complex non-cervical spinal fusion • Congestive heart failure• Chronic obstructive pulmonary disease,

bronchitis, asthma• Diabetes• Double joint replacement of the lower

extremity• Esophagitis, gastroenteritis and other digestive

disorders• Fractures of the femur and hip or pelvis• Gastrointestinal hemorrhage• Gastrointestinal obstruction• Hip & femur procedures except major joint

• Lower extremity and humerus procedure except hip, foot, femur

• Major bowel procedure• Major cardiovascular procedure• Major joint replacement of the lower extremity• Major joint replacement of the upper extremity• Medical non-infectious orthopedic • Medical peripheral vascular disorders • Nutritional and metabolic disorders• Other knee procedures • Other respiratory • Other vascular surgery• Pacemaker• Pacemaker device replacement or revision• Percutaneous coronary intervention• Red blood cell disorders• Removal of orthopedic devices • Renal failure• Revision of the hip or knee• Sepsis• Simple pneumonia and respiratory infections• Spinal fusion (non-cervical)• Stroke• Syncope & collapse• Transient ischemia• Urinary tract infection

CMMI BPCI Episode Choices

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Bundled Payment Pricing

• Required Discount:

• Model 2

• 3% discount for episodes of 30 and 60 days in length

• 2% discount for episodes 90 days in length

• Model 4

• 3% discount for episodes that did not include ACE MS-DRGs

• 3.25% discount for episodes that include ACE MS-DRGs

• Target prices based off 2009-2012 baseline (at this time)

• Risk Adjustment:

• No further risk-adjustment beyond the index MS-DRG; risk adjustment implicit in MS-DRG assignment—based on patient age/sex, co-morbidities and complications as well as diagnoses and procedures

• Outlier Protection:

• Three tracks of varying financial risk based on differential trimming (1/99, 5/95, 5/75; Models 2 and 3 only)

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Target Price Calculations

• Baseline period for target price calculations is July 1, 2009 – June 30, 2012

Payments are trended forward using an annual national episode-specific growth rate

Each MS-DRG has its own target price; these are developed from an episode-level base payment adjusted for MS-DRG weight

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Overview of CMS Pricing Rules

Hospital-

Specific

Experience

Adjustments:

Update factors

Area wage index

Back Out Adjustments:

Area wage index

Case-mix

Apply discount

Target

Price

Apply

Risk Tracks

(based on

National

thresholds)

Apply

Low Volume

Adjustment

Apply

National

Case-mix

Weights

Source: Brandeis University Team Working Document, July 2013 19

Risk Protection

(Outlier Protection)

• Volume matters (general rule > 100 cases in episode)

• May select from three risk tracks (adj. for wage index)

Responsible for 20 percent of payments above high-end threshold for given risk track

– i.e. 20 percent of episode payments above the threshold are included in reconciliation calculations

• May choose different risk tracks for each clinical episode and episode initiator

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Risk Track A B C

Lower Percentile for Winsorization 1st 5th 5th

Upper Percentile for Winsorization 99th 95th 75th

Post-Episode Spending

• Responsible for any excess Medicare spending over a defined benchmark during the 30-day period after an episode ends, within a given confidence interval

Post-episode spending reconciliation will be performed once for each Performance Year

• Benchmark: similar methodology to target price calculations, winsorized at 5th/95th percentiles

• Excess spending will be that spending beyond a 95 percent confidence interval around the benchmark

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IME/DSH

• IME/DSH are excluded from BPCI target prices and prospective payment amounts for both anchor admission and readmissions

Model 2: add-on payments will be paid normally per IPPS

Model 4: add-on payments will calculated as they would be in absence of prospective payment amount, and paid for related readmissions even

though no operating payment is being made

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Quality and B-CARE

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BPCI Quality Metrics

• Quality metrics for program monitoring:

Measures pull largely from existing reporting programs and fall into the domains:

– Structural and organizational characteristics

– Case-mix

– Clinical care and patient safety

– Experience

– Utilization and cost

Requires 5 measures to be submitted by participants (i.e. not currently reported in existing programs):

– Medication Reconciliation Post-Discharge

– STS CABG Composite Score (Mortality and Morbidity Subset)

– Time to Intravenous Thrombolytic Therapy

– Severe Sepsis and Septic Shock: Management Bundle

– Staffing Hours per beneficiary per Day (Inpatient PAC only)

CMMI has not released information on evaluation and/or performance benchmarks

• Measures include hospital, home health, SNF, IRF, and LTCH care sites

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B-CARE Tool

• CMMI is requiring use of the B-CARE tool for the collection of standardized information on beneficiaries’ health status, outcomes of care, and experience of care to evaluate efficacy of care redesigns

Patient status prior to the episode

Significant medical needs

Cognitive and functional impairments and needs

• While B-CARE has been shortened, it is expected to be administered at time of index hospital discharge for all bundled patients and requires significant resources

• B-CARE data collection is currently delayed until Q2 2014

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Waivers

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Model 2 Waivers

• 3-Day Stay Requirement for SNF Payment

Model 2 beneficiaries are eligible for SNF services w/in 30 days of their hospital discharge w/o spending 3 days in the hospital

Partner network to be described in implementation protocols; majority of partner SNFs must be 3-star or better on Nursing Home Compare

Beneficiaries maintain freedom of choice; CMS will monitor which SNFs beneficiaries go to, looking to see that “a majority” go to 3-, 4-, and 5- star SNFs

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Model 2 Waivers

• Post-Discharge Home Visit

New HCPCS G-Code under Physician Fee Schedule

Can be used for non-homebound patients

CMS waiving direct supervision requirement so service can be furnished by an employee of a physician

Can be billed three times during a 90-day episode

Cannot be used for a pre-admission home/safety visit

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Declining Participation in Model 4

• Hospitals interested in Model 4 should pay particular attention to the challenges in physicians’ declining participation

• Physicians and/or non-physician practitioners can decline participation in Model 4 and be paid FFS for Part B services rendered during an inpatient stay

Submit Part B claim with modifier

Must decline participation per service

• Payments made to providers who decline to participate in Model 4 will be drawn back during payment reconciliation

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Fraud and Abuse Waivers

• Savings Pool Contribution Waiver

• Incentive Payments Waiver

• Group Practice Gainsharing Waiver

• Patient Engagement Incentive Waiver

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Bundled Payment Education

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Resource Now Available

Cutting-edge online

modules and resources,

developed in collaboration

with BMJ, to support

clinical team and health

systems in their transition

to new payment models.

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Maximizing Value

Our first offering covers bundled payments and is available in two versions:

• Bundled Payments Essentials

• Comprehensive online learning modules that can be viewed individually or as an integrated course

• Bundled Payments Advanced

• All of the online learning modules in Essentials PLUS a robust set of tools and resources

LEARN MORE! Visit www.maximizingvalue.bmj.org or email maximizingvalue@bmj.com

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If you are seriously considering joining AAMC’s facilitator-convener group, please

send an email to Gillian Smith at gsmith@aamc.org by March 7 to learn more about the convened group and

shared expectations; then a discussion can ensue prior to submission to AAMC of CMMI documents by April 1st, 2014.

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Contact Information:

Coleen Kivlahan, MD, MSPH

Senior Director, Health Care Affairs

ckivlahan@aamc.org

202-828-0053

Melissa Porter, MPA

mporter@aamc.org

202-741-0759

Gillian Smith, MA

BPCI Program Specialist

gsmith@aamc.org

202-741-5515

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