Health Care Reform in Washington State

Carma Matti-Jackson, MBA (TIM)

2.22.2018

1

Today’s Agenda• Overview – CMS Innovation Center

• Funding for Health Care Innovation

• A progress report on models that are in WA state

2

Affordable Care Act Title III, Subtitle APart III, Development of New Patient Care Models

Mandates (by section)

CMS3021. Select Innovation Models to be Tested

(Innovation Awards)

3022. Establish Medicare Shared Savings Program

(Accountable Care Organizations)

3023. Conduct a National Pilot Bundled

Payments

3024. Conduct At Home Medical Demonstration

3025. Hospital Readmission Reductions

3026. Establish a

Community-based Care Transitions Program

3027. Extension of Gainsharing

Demonstrations

Quality Improvement Program

For high readmission hospitals

These were all amendments to various Titles in the Social Security Act, particularly pertaining to Medicare, Medicaid, and the administration of these programs.

3

The Birth of the CMS “Innovation Center”

CMS Innovation

Center

Affordable Care Act (2010),

Section 3021Established the Center for

Medicare & Medicaid Innovation (CMI)

Social Security Act, Section

1115AAuthorized CMI

4

Innovation Center: Purpose & Mission

SEC. 1115A. [42 U.S.C. 1315a] (a) (1) “The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles.” –Social Security Act

Purpose:

• Test innovative payment and service delivery models

Mission:

• Reduce program expenditures

• Simultaneously preserve or enhance quality

Affordable Care Act Title III- All Subparts• Part I “linked payments to quality outcomes under the Medicare program” (Value Based Purchasing). • Part II created the “National Strategy for Quality Improvement in Health Care” (Quality Programs)• Part III created CMI to test new models to reduce expenditures (without sacrificing quality).

5

Innovation Center: Ultimate Goal

Expand models (including on a nationwide basis) that:

• Reduce program spending without reducing the quality of care; or,

• Improve the quality of care and reduce spending.

Models need to be tested on the worthiness towards expansion.

• During the testing phase, models need not be budget neutral.

• All models tested must be terminated or modified unless it is found they meet the criteria for expansion.

• Termination may occur any time after testing has begun and before testing is complete.

Determining criteria necessary to meet the goal:

• The Chief Actuary of CMS must certify that such an expansion would reduce program spending.

6

How the Innovation Center is Financed

Funding was appropriated for the CMS Innovation Center in the same section of the ACA in which it was created (Section 3021). This is now found in 1115A of the Social Security Act:

• $5 million for fiscal year 2010

• $10 billion for fiscal years 2011 through 2019 (Money is available until expended).

• “Not less then $25 million must be used each year to design, implement, and evaluate models.”

• $10 billion per decade beginning in fiscal year 2020 (Money is available until expended).

7

Innovation Center Annual Obligations & Outlays

$813

$953

$1,181

$1,351

$1,829

$95

$656

$997 $971

$1,408

$1,595

2011 2013 2014 2015 2016 2017

Dollars in Millions

Total Obligations Total Outlays

8

Innovation Center Cost of Administration and Oversight

$0

$50

$100

$150

$200

$250

$300

$350

$400

2011 2013 2014 2015 2016 2017

ABOUT $340 MILLION PER YEAR

Innovation Supports Administrative Expense

9

Innovation Center: How the Organization has Changed Over Time

THEN: Nine Groups, 163 FTEs(One Full Year After Implementation)

Research and DevelopmentTechnical

Assistance Awareness & Vetting

(Identifies ideas for further development)Former CMS Office of

Research

Patient Care

Models Group

Seamless Care

Models Group

Community Improvement

Models Group

Learning & Diffusion

Group

Stakeholder Engagement

Group

Program & Policy Group

Rapid Cycle Evaluation

Group

Portfolio Management

Committee

Medicare Demonstrations

Program Group

NOW: Eight Groups, 617 FTEs(January 2018)

Patient Care Models Group

Seamless Care Models Group

Prevention & Population

Health Group

Research & Rapid Cycle Evaluation

Group

Learning & Diffusion

Group

Business Services Group

Policy & Programs

GroupState

Innovations Group

10

Innovation Center Activities

• Testing and oversight of Medicare Shared Savings Program + (MSSP+)

• Merit-Based Incentive Payment System (MIPS)

• Quality Payment Program (QPP)

• Advanced Alternative Payment Models

• Health Care Payment Learning & Action Network (LAN).

• Initiative to Reduce Avoidable Hospitalizations among SNF Residents

• Medicare/ Medicaid financial alignment initiative

11

In addition to testing Health Care Innovation Models as described in Section 3021 of the ACA, the Innovation Center has assumed responsibility and collaborative oversight of many additional activities including items established in the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) and the 2016 Quality Payment Program. Here are a few of those activities:

• The development of models recommended by the Physician-Focused Payment Models Technical Advisory Committee (PTAC)

• Partnerships for Patients

• Transforming Clinical Practices

• Medicaid & CHIP Innovation models

• Accountable Communities of Health

• Bundled Payments

• Initiatives that were already in progress under the Medicare Demonstration Program Group (such as Money Follows the Person)

Patient Care

Models Group

(5 Divisions)

Technical Model

Support

Payment Models

Health Care Payment Models

Specialty Payment Models

Ambulatory Payment Models

Seamless Care

Model Group

(5 Divisions)

Advanced Primary Care

Financial Risk

Special Populations and Projects

Seamless Infrastructure

Delivery System

Demonstration

Prevention and

Population Health Group

(3 Divisions)

Health Care Delivery

Health Innovation

and Integration

Population Health

Incentives and Infrastructure

Research & Rapid

Cycle Evaluation

(4 Divisions)

Health System Research

Payment & Accountability

Research

Special Populations

Research

Data, Research & Analytical

Methods

Learning & Diffusion

Group

(3 Divisions)

Model Learning Systems

Cross-Model Learning &

Improvement

Improvement Networks &

Regional Engagement

Business Services Group

(5 Divisions)

Budget & Administrative

Services

Central Contract Services

Application Design &

Development

Information Technology

Operations & Security

Program & Project

Management

Policy & Programs

Group

(4 Divisions)

Alternative Payment

Model Infrastructure

Stakeholder Engagement &

Policy

Portfolio Management

Strategy

Data Analytics

State Innovation

Group

(2 Divisions)

State Innovation

Models

All-Payer Models

Today’s Innovation Center31 Divisions Managed by 39 Directors & 11 Deputy Directors

12

How CMI Staffing “Fits” in the Overall Picture

CMS Administration74%

Fraud & Abuse8%

Other7%

Innovation Center

Affordable Choice Plans

Sunshine Act (transparency)

Misc. ACA staff

Affordable Care Act11%

CMS FTEs = 6,7951

Affordable Care ACT (mandatory)

= 710 FTEs2

Of those, 87% staff the Innovation Center.

NOTES: Federal Law does not typically call out a specific number of FTEs to manage programs. However, the CMS FY2018 budget brief identifies staff as Mandatory and Discretionary. “Mandatory” means required by statute. CMS Administration staff are considered “Discretionary” meaning not directly funded in statute. ACA staff are considered “Mandatory.” About 47% of Health Care Fraud & Abuse staff are considered “Mandatory.” Quality staff (QIO) makes up about half of the “Other” category. Where there were FTEs identified as both ACA staff and Quality or Fraud and Abuse, those FTEs were counted in ACA .

13

Innovation Demonstration Projects

• About 40 models* have been or are in process of being tested. There are variations within each model that are also being tested. (For example, some models allow providers to choose risk bearing tracks or payment methodologies.)

• Of the models that have been tested, two have been certified by the actuary for expansion:

• Pioneer Accountable Care Organization Model

• Medicare Diabetes Prevention Program

• About $1.9 Billion has been awarded for Innovation Demonstrations (including State Innovations). This does not count funding awarded for projects that are not in the “Innovation Awards” category, but are still related to health reform.

• WA has been the beneficiary of about $165 Million worth of innovation projects.

14

*Taken from the CMS CMMI Report to Congress, Dec. 2016. A hand count has this closer to 70 models that have been or are being tested.

Accountable Care Organizations

Population-Based PaymentsShared Savings/Risk(Moves toward Capitation Rate)

15

Accountable Care Models in WA

• Medicare Shared Savings Program (MSSP) ACOs

• Track 1: One-sided risk (savings or “upside” risk only)

• Track 1+: Two-sided (savings & loss or “upside & downside” risk)

• Next Generation ACO Model

• Comprehensive End-Stage Renal Disease Care Model

13 ACOs total in WA

7 ACOs Currently Practicing in WA:• 5 MSSP ACOs (1 Full Risk, 4 savings risk only)• 1 Next Generation ACO• 1 ESCO (End -Stage Renal Diseases (ESRD) Seamless Care Organization)1 ACO set to renew5 new ACOs that were initiated January 1, 2018:• 4 One-sided risk• 1 two-sided risk

16

Accountable Care In GeneralFocus is centered on a specific population.

Historical costs on qualifying claims

Target Population

Account for Trends

Adjust for Risk

Defined Beneficiary for Medicare:• Must be enrolled in Part A and

Part B, & must be traditional FFS• 1 or more eligible claim within

the ACO (a primary service)• Resident of USA

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Accountable Care In General

• Providers that participate work together to try to achieve efficiencies. (Standard protocols & best practices).

• Participants must agree to work on and report quality information.

• Costs are reconciled to the benchmark price. If costs are lower than the benchmark, “savings” is achieved.

• If certain criteria are met (depending on the model)such as minimum levels of savings, quality, etc.,

the ACOs gets to share in that savings and may distribute a portion of the savings to the participants of the ACO. Some models also have shared losses.

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General Flow Chart- ACO Payments(All payments on the population count towards shared savings, even if they are provided by non ACO providers)

CM

S ACO Participants

Preferred Providers

ACO

• Claims submitted & paid normally through FFS.

• ACO chooses advanced payment unrelated to claims for infrastructure costs.

• All payments to ACO recouped during reconciliation regardless of savings or loss

• Shared Savings & Next Generation

CM

S ACO Participants & Preferred Providers

ACO

All-Inclusive (capitated)

• Claims submitted normally• CMS sends ACO claim info &

payments• ACO distributes payments to

providers• Next Generation Only

CM

S

ACO Participants (& Preferred Providers)

ACO

Partial Capitation

• Calculate a % reduction from baseline.

• Providers bill normal FFS• CMS pays FFS discounted by % • CMS pays savings to ACO• ACO distributes shared savings

to participants• Shared Savings & Next

Generation

Bills 100%

Pay Less than 100%

SavingsAdvanced Infrastructure payment (AIM)

Sends Claims

Payment

Claim Info & payment

Infrastructure Advance

Regular Fee For Service19

• Upside only model.

• Beneficiaries retrospectively assigned.

• Benchmark- 3-year historical.

• Minimum savings 2-3.9%.

• Share up to 50%.

• Cap- 10% over benchmark.

• Renewable one-time only.

• Ended

• 3 years w/2 year renewal.

1+

• Lowest risk 2-sided model.

• Beneficiaries prospectively assigned.

• Benchmark = Track 1.

• Minimum savings= Track 1.

• Share & Cap = Track 1.

• Minimum loss rate on benchmark or revenue.

• Fix loss rate = 30%.

• Waiver 3-day SNF rule

• 3 years

1

• Option for full capitation.

• Beneficiaries prospective & voluntary.

• Benchmark: 1-year historical data trended forward. Discounted for quality & efficiency.

• No Minimum Savings or Loss.

• Share in savings & loss 80%/85% or 100% for capitation.

• 4 payment options.

• Waiver: SNF 3-day, Telehealth, Post Discharge Home visits.

•3 years w/2 years extension

• Upside only model.*

• Beneficiaries assigned. Aggregate of participating providers based on “first touch.”

• Dialysis & Nephrology shared risk. Others optional.

• Benchmark- 3 year historical.

• Minimum savings 2 - 4.75%.

• Share up to 50%.

• Cap- 5% over benchmark

• Ends 12/2020

Compare ACO Financial Models in WA State

MSSP Track 1MSSP Track 1+ (Innovation Test)

Next Generation (Innovation Test)

Comprehensive ESRD Care

(Innovation Test)

*Note: ESCO has a 2-sided model, but it does not apply to the ESRD Model in WA state.20

ACOs Currently Practicing in WA

The Polyclinic

Launch: 7/2012

Renewed: 1/2016

Group Practice: Physician Led & Multi- Specialty

Area: Greater Seattle

MSSP – Track 1

Savings Only

Rainier Health Network

Launch: 1/2013

Renewed: 1/1/2016

CHI Franciscan Health

Area: King, Pierce, & Kitsap

Shared Savings To-date: $3 M

20% Infrastructure

20% Redesign care processes

60% Participants

MSSP – Track 1+

Savings & Losses

Health Connect Partners

Launch: 1/2014

Renewed: 1/2017

Providence

Multiple States: WA, CA, AK

Area: Spokane, Benton, Walla Walla Stevens, Mason, Lewis,

Thurston, Snohomish

MSSP– Track 1

Savings Only

Rainier Health SNF Network• Park West Care• Burien Nursing / Rehab • Judson Park • Garden Terrace • Cottesmore • Orchard Park Rehab • Evergreen (Tacoma)• Life Care Puyallup• Life Care South Hill• Martha & Mary• Stafford Belmont & SeaTac• Tacoma Lutheran• Wesley Homes

USMM Partners

1st agreement (2015) concluded

Renewal Projected: 1/2019

Home-based ACO

Visiting Physicians Association, Homescripts, Home DME

Multiple States: WA, VA, WI, OH, TX, MO, MI, IN, IL, FL

Area: WA Based in Renton

Shared Savings To-date: $28 M

25% Infrastructure

54% Redesign care processes

21% Participants

MSSP— Track 1

Savings Only 21

ACOs Currently Practicing in WA

Magnolia

Evergreen

Launch: 1/2016

Caravan Health (Astria)

Multiple Critical Access & Rural Health States: WA, ID, MS

Areas: Douglas, Grant, Lincoln, Okanogan, Asotin, Columbia,

Rural Yakima

MSSP Track 1 & Investment (AIM)

Savings Only

Northwest

Momentum Health Partners

Launch: 1/2017

Physicians of Southwest WA

Distribution Plan:

20% Infrastructure

20% to Providers (75% Participants & 25%

Preferred)

40% Investment and reserves

20% Equity Owners

Area: Greater Olympia

Next Generation

Savings & Losses

Northwest Kidney

Alliance

Launch: 1/2017

Dialysis Provider Organization

Area: Greater Seattle Comprehensive ESRD Care

Savings Only

Rocky Mountain

Launch: 1/2016

Rural, Critical Access, FQHC & RHC

Multiple States: WA, ID, CO

Areas: Grays Harbor, Klickitat, Jefferson, Mason,

Pend Orielle

MSSP Track 1 & Investment (AIM)

Savings Only

Northwest Momentum LTC Participants

• Olympia Nursing Home Consultants (SNF Home Visit)

• South Sound Medical (SNF Home Visit)

Preferred Providers• Prestige Post Acute & Rehab• RooLan• Manor Care (Lacey)• Olympia Transitional Care• Puget Sound Health Care• Sharon Care Center• Nisqually Valley Care Center• Assured Home Health &

Hospice• Faith Home Care• Infinity Rehab (home care)

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Initial WA ACOs: Began January 2018

Cascadia Care Networks

Hospitals & Physicians (CIN)

Areas: Skagit and Snohomish

MSSP– Track 1

Savings Only

KootenaiClinically Integrated

Network (CIN)

Multiple States: WA, ID

Area: Coeur d'Alene (Spokane??)

MSSP Track 1

Savings Only

Community

Health Center

Network of Idaho

Joint Venture includes

Community Health Association of Spokane

Multiple States: WA, ID

Area: Spokane

MSSP— Track 1

Savings Only

Multicare Connected

Multicare physicians and clinicians (CIN)

Area: Pierce & South King County

MSSP— Track 1+

Savings & Loss

SNF 3 day Waiver

Valley Medical Group

Public Hospital #1 of King County

Area: Renton, South King County

MSSP— Track 1

Savings Only

Multicare Connected SNF Network•Regence Puyallup•Life Care South Hill•Tacoma Lutheran

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CIN: Clinically Integrated Network

Are Medicaid ACOs Coming?

Center for Health Care Strategies, Inc.https://www.chcs.org/project/medicaid-accountable-care-organization-learning-collaborative-phase-iv/

24

Bundled Payments –Episode-Based Payments(Moves toward Case Rate)

Is this LEAN in the Healthcare World?

“Time-Driven Activity Based

Costing”

Focus on “needed services.”

25

“Organization & Process

Mapping”

BPCI Compared to ACOs

BPCI Model

• Focus on Cost Reduction.

• At risk for a small subset of the population (hand selected by choosing diagnosis).

• Target price benchmark separately for each diagnosis.

• Individual participants are only accountable for the episodes they sign up for.

• Focus on efficiencies after a person is diagnosed.

• Gains achieved through efficiencies in the supply chain.

• Gains/losses are shared based on where the efficiencies are a achieved or lost.

ACO Model

• Focus on Payment Reduction (Revenue).

• At risk for an entire population (typically geographic).

• Target price benchmarks on the whole costs for the entire population.

• Individual participants are accountable for the population as a whole.

• Focus on prevention services & keeping the person out of a high cost setting.

• Savings achieved by reducing utilization.

• Shared savings/loss are applied to all participants.

26

BPCI Model In General

27

Episode 1 Target Price

Episode 2 Target Price Episode 3

Target Price

Target price & episode definitions (what conditions are included) are proposed by the risk bearing applicants, and set by CMS.

Providers work together to LEAN their processes and activities– for each episode.

CMS Pays full FFS to providers.

Gains are shared among the episode participants & the convener when the episode is below the target price.

Payments are reconciled to the price for each episode.

Bundled Payment for Care Improvement (BPCI) Models in WA

• BPCI Model 2: Retrospective Acute & Post Acute Care Episode

• BPCI Model 3: Retrospective Post Acute Care Only

• Oncology Care Model

11 Currently in WA8 Bundled Payment Provider Organizations (BPPOs) with 31 BPCI Contracted Participating Organizations (risk bearing)• Four BPCI Model 2• Four BPCI Model 3

3 Oncology Care Model Organizations

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BPCI General Overview• Gain Sharing Models

• Target Price is based on diagnostic episodes:

• Oncology Model has 12 cancer specific episodes.

• BPCI Model 2 & 3 have 48 diagnostic episodes to choose from.• Model 2 participants have chosen 41 distinct episodes

• Model 3 participants have chosen 14 distinct episodes

• Overlap with Accountable Care & Shared Savings programs is permitted

Risk Bearing StructuresBPCI typically has two risk bearers:1. A participating provider (Single Awardee) assumes financial risk for episodes

initiated by them. Several join together to become the Bundled Payment Provider Organization (BPPO). They may share in episodes or have different ones.

2. A parent company, health system, or other organization may assume financial risk for the entire BPPO. These are typically “Conveners”- although not all conveners bear risk.

Oncology Care Model has a more flexible structure: Physician practices, physician groups, and insurers may participate. It is a multi-payer system, so payments also come from commercial insurance.

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Comparison Of BPCI Programs in WAComparison Item BPCI Model 2 BPCI Model 3 Oncology Care Model (OCM)

Launch 2015 Phase II (risk bearing) 2015 Phase II (risk bearing) 7/2016

Ends September 30, 2018 September 30, 2018 Must move to 2-sided risk in 2019 or end. Otherwise end June 2021

Initiators Hospital or physician group SNF, inpatient rehab, home health, physician group

Physician group.

Episode Trigger Inpatient admission (Anchor stay or procedure)

PAC admission within 30 days of hospital discharge

Receipt of qualifying Part B or Part D chemotherapy claim

Episode length (WA)

90 days 90 days 6 months

What’s counted?

Part A & B: Inpatient hospital, inpatient physician, hospital readmission (some exceptions), all post-acute care & other services. No hospice.

Part A & B for post-acute care. Includes physician services & hospital readmissions (some exceptions). Excludes hospital stay & any services before the episode trigger.

Part A, B, and some Part D.Includes inpatient, hospice, & drugs. Readmissions if they fall within the 6 month period.

CMS discount from the target

2% 3% 4% 1-sided or 2.75% 2-sided

Gain Sharing Stop-loss is 20% of spending above the upper limit of selected risk track (3 tracks to choose from).

Same as Model 2 Loss and/or gain limits are 20% of the benchmark. (1-sided or 2-sided options)

Other Waivers: 3-day SNF, Telehealth, Post Discharge home visit, beneficiary incentive waiver

Waivers: Telehealth, Post Discharge home visit, beneficiary incentive waiver

- Payment tied to Quality- Includes $160 PBPM for Care Management -Commercial payers participate.Waivers: Beneficiary incentive

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Quotes form the BPCI Models 1 & 2 Year Three Evaluation*

• Providers that chose to participate in BPCI are larger and appear to have more resources than providers that did not participate.

• A majority of Awardees indicated in their agreements with CMS that they wanted options for beneficiary incentives, program rule waivers, & gainsharing. However, use of these options was limited.

• Gainsharing plans were included in the agreements of 61% of Model 2, but only 18% distributed funds.• Gainsharing plans were included in the agreements of 15% of Model 3 and 43% distributed funds. • Most gainsharing funds were mostly distributed to physicians in both Model 2 and Model 3.

• Under Model 2, participants reduced institutional PAC. (Discharged Home)

• There were few statistically significant differences in quality of care under Model 2

• Unplanned readmissions within 90 days of SNF admission did not decline as much in BPCI participating-SNFs (Model 2) as in comparison SNFs under Model 3

• Assessment-based measures for PAC users in Model 2 episodes did not indicate systematic quality issues relative to the comparison group

• There were few instances in which patient complexity appeared to change for BPCI participants from baseline to intervention period

• Hospitals Episode Initiators with greater use of PAC admission for Major Joint Replacement and Congestive Heart Failure achieved higher per-episode Net Payment Reconciliation Amounts under Model 2.

• There were few instances in which patient complexity appeared to change for BPCI participants from baseline to intervention period

*Lewin Group, October 2017: “Bundled Payments for Care Improvement – Third Evaluation Report.” https://downloads.cms.gov/files/cmmi/bpci-models2-4yr3evalrpt.pdf

31

Bundled Payment Provider OrganizationsModel 2: Acute & Post Acute Care

32

Convener: Liberty Health

Pierce County, WA

(41 Episodes)

American Physicians

Inc

Inpatient Services,

Pc Robert A. Bessler,

M.D., PLLC

Sound Inpatient Physicians (4 entities)

Sound Kenwood

Hospitalists

Sound Physicians

(6 entities)

South Sound

Inpatient Physicians

Convener: Signature

Medical Group

Southwest WA(2 Episodes in WA)

NW Surgical Specialists

Vancouver, WA

Olympia Orthopedic

Olympia, WA

Orthopedic & Fracture

Clinic

Portland, OR

Slocum Orthopedics Eugene, Or

Convener: Premier, Inc

Longview, WA(1 Episode in WA)

St. John’s Medical Center

Longview, WA Peacehealth

Sacred Heart

Springfield, OR

Convener: Catholic Health

Services

St. Joseph Medical Center

Tacoma, WA(1 Episode)

Bundled Payment Provider OrganizationsModel 3: Post Acute Care

33

Convener:

AvamereWhatcom,

Greater Seattle (34 Episodes)

St. Francis Operations

(SNF)

BellinghamAvamere

Home Health

Bellingham

Richland Beach Rehab

Shoreline

Bellingham Operations (Bellingham Health Care and Rehab)

Seattle Operations

Queen Anne Healthcare

A-One Home Health

Services Bellevue

Prime Home Health Federal

Way

Convener: Liberty Health

Pierce County, WA

(14 Episodes)

American Physicians

Inc

Inpatient Services, Pc

Robert A. Bessler,

M.D., PLLC

Sound Inpatient Physicians Sound

Kenwood Hospitalists

Sound Physicians

Convener: Santa Fe

OperationsNorthwoods Lodge

Silverdale, WA

(10 Episodes)

Convener: Ensign ServicesPark Manor Rehab

Walla Walla, WA

(4 Episodes)

Oncology Models in Washington State

34

Northwest Cancer

Specialists (Compass)

Southwest, WA

Vancouver, WA

North Portland,

OR

Southeast Portland,

OR

Central Portland,

OR

North Star Lodge

Yakima Valley Memorial Hospital

Yakima, WA

Northwest Medical

Specialties

Pierce County

Tacoma, WA

Gig Harbor, WA

Puyallup, WA

Federal Way, WA

Bonney Lake, WA

Lakewood, WA

10 bundles by type of cancer (12 episodes)

Medicare Care Choices Model (MCCM)Curative Care & Hospice Simultaneously

35

Medicare Choices• CMS will provide payment for hospice concurrently with

curative care.

• The model is diagnosis based. Beneficiaries must:

• Have a qualifying terminal illness: Advanced cancers, chronic obstructive pulmonary disease, congestive heart failure, or HIV/AIDS;

• Meet hospice eligibility requirements under Medicare or Medicaid;

• Have had at least one hospital-based encounter in the last 12 months (emergency department visit, observation stay or admission);

• Have had at least three office visits (with a Medicare-certified provider for any reason); and

• Must not have elected the hospice benefit within last 30 days.

36

MCCM Participants in WA• Participating Hospices are paid $400 PBPM for 15 or more

calendar days of services. Fewer than 15 days are paid $200 PBPM. Medicare Hospice Benefit per diem rates are not available concurrently.

• Round 1 Participants began the model in January 2016. The demonstration expires January 2020.

• WA has two Round 1 Participants:

• Yakima Valley Memorial Home Care Services (Yakima Valley Memorial Hospital)

• Hospice of Spokane

37

Million Hearts: Cardiovascular Disease Risk Reduction Model

38

Million Hearts Model Overview

• Incentive Payments to implement beneficiary risk calculation & stratification using a risk calculator.

• Encourages providers to develop a risk modification plan based on beneficiary risk profiles.

• Participants: Family practice, community health, private practice, or any clinic, hospital, or physician group. The practice must have at least 1 practitioner (may be a PA and Nurse Practitioners).

• Target Population: Medicare FFS, ages 40-79 who have not had a previous heart attack or stroke. Indicators that will put the beneficiary into the risk cohort: Abnormal cholesterol levels, systolic blood pressure, use of statin therapy, medication for hypertension, smoking, and diabetes.

• One-time payments of $10-$20 per beneficiary for the risk assessment & submission of data. $20 PBPM for care management.

39

Million Hearts Model Participants in WA

Provider Location

O'Connor Family Medicine, PLLC Spokane, WA

Columbia County Hospital District Dayton, WA

Virginia Mason Medical Center Seattle, WA

Swedish Heart and Vascular Seattle, WA

Summit View Clinic Puyallup, WA

Douglas, Grant, Lincoln, Okanogan Counties PHD #6Grand Coulee, WA

GIM Services PLLC dba Pacific Family & Internal Medicine

Sequim, WA

Auburn Family Medical Center Auburn, WA

Implementation began January 2016 and will end December 2020.

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Transforming Clinical Practice Initiative (TCPI)

41

TCPI Overview

• The CMS Innovation Center provided several awards to organization to support them and offer technical assistance to clinicians who want to shift to value based-payments.

• Support is collaborative & peer-based.

• May not be overlapped with bundled payments.

• A total of $685 million was awarded to cooperative agreements over a 4-year period.

• Round 2 Awards were provided September 2015.

• Washington is the beneficiary of seven of the awards.

42

TCPI Awards in WA

National Rural Accountable Care Consortium

Up to $31 Million

• 2015-2019

•Targeted Participants: Rural primary care, behavioral health, & specialty providers.

•Serves multiple states.

•Train, certify and mentor care coordinators

•Implement the necessary IT infrastructure to set up billable care coordination

•Provide a federally funded 24/7 nurse advice hotline

http://www.nationalruralaco.com/practice-transformation.shtml

PeaceHealth Ketchikan Medical Center

$3.7 Million

•2015-2019

•Builds on a Round 1 Grant of $3.1 Million

•Targeted Participants: Medicare quality reporting staff, critical access hospitals, FQHCs, FFS clinics.

•Serves multiple states.

•Implementation of team-based models.

•Implement an integrated system-wide EMR. Integrate clinical findings, health metrics data, and chronic disease registry outcomes.

UW Medicine

$5.5 Million the first year. Up to $50.2 M over 4

years.•2015-2019

•Targeted Participants: Statewide.

•Serves multiple states.

•Collaborative learning groups to foster adoption of best practices.

•Training & skill building in quality improvement, process improvement, and change management.

http://www.uwmedicine.org/about/transformation

Washington Association of Community & Migrant

Health Centers

•2015- 2019

•Targeted Participants: Statewide

•Quality Improvement Best Practices & Tools

•Coaching on Patient Centered Medical Home

•Training on Clinical Quality Measures

http://www.wacmhc.org/programs/quality-improvement-practice-transformation

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TCPI Awards in WA (continued)

Washington State

Dept. of Health

Up to $16.3 Million

• 2015- April 30, 2019

•Targeted Participants: primary care & behavioral health pediatric practices. Focus on underserved areas.

•Partners with WA Chapter of American Academy of Pediatrics.

• Support for behavioral health integration.

•Health Home Care Coordination training.https://www.pcpcc.org/initiative/ptn-washington-transforming-clinical-practice-initiative-–-pediatrics-tcpi-p

Washington State

Dept. of Health

$3.2 Million

•2016-2019

•Builds on a Round 1 Grant of $3.1 Million

•Targeted Participants: Primary care & Behavioral Health Providers. Small/medium practice with fewer than 20 providers.

•Readiness Assessment

•Regional practice coaches

•Regional & statewide training.

http://www.waportal.org/

VHA/UHC Alliance

“Vizient”

•2015-2019

•Targeted Participants: Multiple states including WA.

•QI Advisors

•Reimbursement for a designated project leader

•Data & Metrics

•TCPI change packagehttp://newsroom.vizientinc.com/newsletter/education-and-collaboration-news/practice-transformation-networks-demonstrating-penchant-

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Other Innovation Center Awards

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Health Care Innovation Awards in WA4 year awards

• $2.7 Million awarded to the National Health Care for the Homeless Council. The project will provide medical respite care for homeless Medicaid & Medicare beneficiaries. It covers Washington, Arizona, Oregon, & Minnesota.

• $5.6 Million awarded to Seattle Children’s Hospital to test the implementation of Pediatric Partners in Care (PPIC).

• Up to $65 Million awarded to the State of Washington for the Healthier Washington project to:

• Implement Accountable Communities of Health

• Redesign payment, through shared savings & total cost of care in collaboration with delivery system & payer partners.

• Enhance analytics, interoperability, and measurement.

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WA State Accountable Communities of Health

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Where do we go from here?

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Our Current Environment• Medicare’s annual per capita growth over the past five years has been hovering

around 4.3% (it was around 10% when the ACA was enacted).

• It’s much closer to private health insurance which grows around 4.5% annually. (This was around 5% when the ACA was enacted).

• The nation’s $14 Trillion debt continues to grow. Expenditures continue to increase and revenues remain flat, creating a growing annual deficit ($600 billion as of 2016). Congressional Budget Office says the budget needs to change by $380 billion beginning in 2018 just to maintain the current situation (increase revenue or reduce spending).

• Unless changes are made, Medicare reserves are projected to deplete by 2029- requiring cuts to sustain the program (Medicare Board of Trustees Report).

• Unless changes are made, Social Security reserves are projected to be depleted by 2039-requiring cuts to Old Age and Survivor benefits to sustain the program (OASI and DI Board of Trustees Report.

• The projection on the amount of savings that can be realized from these models varies greatly. Some say it’s only around $1 Billion over 10 years in terms of hard dollars. Others report its $30-$40 Billion or more over ten years when considering what costs might have been otherwise.

• CMS recently announced a “New Direction” for the innovation center. The emphasis is on “Market-Driven” reforms over policy driven reforms.

• The next $10 Billion allotment is due in 2020.

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What is publicly underway?• The Innovation Center is currently accepting applications on two

new demonstration programs that would continue well beyond 2020:

• BPCI Advanced (Round 1 this year, Round 2 in 2020)• Expanded Diabetes Prevention Model

• Applications are under review for the Medicare Advantage Value-based Insurance Design Model.

• The Innovation Center has listed “Models under development:”

• Regional Budget Payment Concept (based on the Maryland all payer model)

• Advanced Primary Care Initiatives

• Health Plan Innovation Initiatives

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Innovation Center Activity Timeline

2010

•$5 Million:

• Innovation Center Began

2011

•$10 Billion

•MSSP established

•FQHC advanced primary care practice model.

•Multipayer Primary Care

• Innovation Advisor Program

2012

•Round 1: Shared Savings

•Pioneer ACO

•Advanced Payment ACO

•Round 1: Innovations

•Round 1 State Projects.

•Round 1: BPCI

2014

• Dual Eligible Integration

• FQHC PCPM ends.

• Round 2 Innovation

• Round 2 State Innovation

2015

• Pioneer ACO Certified

• Round 1 Innovation Ends

• Round 1 State Projects End

• TCPI

2016

• Pioneer ACO Ends

• Oncology Care

• ACO Investment Model

• Diabetes Prevention Model Certified

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2018

• BPCI 2&3 End

• Round 1 BPCI Advanced

• Expanded Diabetes Prevention model

2019

• Round 2 Innovation Ends

• Round 2 State Innovation ends.

• TCPI ends

2020

• $10 Billion

• Next Generation ends

• ESRDC ends

• Round 2 BPCIAdvanced

2021

• Oncology Care ends

2023

• Round 1 BPCI Advanced Ends

2025

• Round 2 BPCI Advanced Ends

Questions

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Appendix: Definition of AGO & BPCI Waivers

• Skilled Nursing Facility 3-day Rule Waiver: Beneficiaries can be admitted directly to a SNF from their home, a physicians office, or when they have been in the hospital fewer than three days. (Must be 3 stars or better)

• Telehealth Waiver: Not dependent on where the beneficiary lives, or where care originated.

• Post Discharge Home Visit Waiver: Allows home visits by providers that are not home care. Medicare will pay for a licensed clinician’s visit within the first 10 days after discharge and a second visit in the subsequent 20 days.

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