Home Health Value Based Purchasing – 2016 and Beyond

Chris Attaya, VP Business Intelligence, SHP

Rey Spadoni, President, Partners HealthCare at Home

Sixth Annual New England Home Care & Hospice

Conference and Trade ShowMay 17, 2016

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About the Partners HealthCare System

$11B health care system founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital, Partners HealthCare System (PHS) includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities.

• Per the US News 2015-16 Ranking:• Massachusetts General Hospital #1• Brigham & Woman’s Hospital #6• Spaulding Rehabilitation Hospital #6 Rehab• Massachusetts Eye & Ear #1 ENT• McLean Hospital #4 Psych

• A teaching affiliate of Harvard Medical School; national leader in biomedical research.

• Partners is the largest private employer in Massachusetts, with approximately 60,000 employees, including physicians, nurses, scientists, and caregivers.

About Partners HealthCare at Home

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• $95m home health agency established in 2000 with the merger of 27 VNAs

• Certified home health care services, per year…• ADC 3,700• Admissions 27,000• Visits 470,000

• Private care services, per year• ADC 1,100• Hours 450,000

• Special programs

• Telemonitoring

• Mobile observation unit

• Wound care

• Infusion

• Pediatrics

• Enterprise technology platform: Epic (May 2015)

• Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program

• Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement

• Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP

Learning Objectives

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Learning Objectives

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• Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program

• Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement

• Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP

• CMS HHVBP Goals• OASIS, Claims and HHCAHPS Measures• New Measures• Piloted States Selection Criteria• Measure Points Scoring• Larger vs Small volume HHA Cohorts• Important Updates from CMS Q & A’s• HHVBP Connect Site

HHVBP Components

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CMS is proposing the use of quarterly performance reports, annual payment adjustment reports, and annual publicly-available performance reports as a means of developing greater transparency of Medicare data on quality and aligning the competitive forces within the market to deliver care based on value over volume

CMS HHVP Goals

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Measures by NQF Domain

DOMAINS

1) Patient and Caregiver centered experience 2) Clinical Quality of Care

3) Communication & Care Coordination 4) Population Health

5) Efficiency and cost reduction 6) Safety

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• Each of these new measures will need to be reported by HHAs through a Web Portal starting with Q3 data

New Measures

Measure Measure Type Notes

Influenza Vaccination Coverage

for Home Health Care

Personnel

Process % HHA personnel received or documented not received – medical condition, received elsewhere, declined, unknown. Need to have worked 1 day Oct 1 to March 31st

Herpes zoster (Shingles)

vaccination: Has the patient

ever received the shingles

vaccination?

Process # of Medicare beneficiaries over 60 that ever received shingles vaccine

Advanced Care Plan Process Patients over 18 with plan or discussed with patient (no surrogate or plan made)

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Review and understand the numerator and denominator values before starting data collection

New Measures for the Portal

• Do not wait to start collecting even though they are not due to be submitted until October 7th, 2016

• Centralize the collection and reporting within your organization

• Conduct your own dry run to ensure you have the data available and ready to enter into the Portal

• Plan to enter a least a week before they are due to make sure there are no glitches!

Example of Herpes Zoster

• 13 questions need to be collected in this example

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• Domains into Classifications

Domains into Classifications

Classification IClinical Quality of

Care

Classification IIOutcome & Efficiency

Classification IIIPerson & Care-giver-Centered

Experience

Classification IVNew Measures

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Randomly Selected States

Piloted State Selection Criteria

The 9 pilot states are: Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee

Started with nine geographically-defined groupings of five or six states based on geographic, sample size and patient characteristics

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Each Measure will have points scored based on the higher of an achievement score or improvement score

• Using the Base Year Period two calculations are set

• Threshold Value – 50th percentile (Median)

• Benchmark – Mean of the top decile (~95 percentile)

• Base Year (Calendar Year 2015) will not change

• Performance Years 2016 – 2020

• Each measure needs 20 or more episodes to be included in the total performance scores

• New Measures will be scored based on self reporting data only

Measure Points Scoring

• Measure Points Scoring (cont.)

Measure Points Scoring (cont.)

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• Awarded by comparing an individual home health agency’s rates during the performance period with all home health agency’s rates from the baseline period

– Rate equal to or better than the benchmark: 10 points

– Rate less than the achievement threshold: 0 points

– Rate equal to or better than the achievement threshold and worse than the benchmark: 0 – 10 points

Measure Points Scoring (cont.)

Achievement Points – By Pilot State

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• Awarded by comparing an individual home health agency’s (HHA’s) rates during the performance period with that same individual HHA’s rates from the baseline period.

– Rate equal to or better than the benchmark: 10 points

– Rate worse than the agency’s base year rate: 0 points

– Rate equal to or better than the agency’s base year rate and worse than the benchmark: 0 – 10 points

Measure Points Scoring (cont.)

Improvement Points – By Agency

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• Measure Points Scoring (cont.)

Measure Points Scoring (cont.)

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• Agencies reporting will be broken down in 2 Cohorts –Large: HHCAHPS Participant, and Small (Exempt from HHCAHPS due to <60 eligible patients in the calendar year)

• Intention to is group “like agencies” for performance reporting

Large vs. Small Agency Cohorts

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• CMS quarterly will provide each agency with their scores• The first report will be available in July 2016 for the 2016 Q1 data

• Agencies will have the opportunity to contest their scores within 30 days of receiving

• Agencies will also have a chance to review their TPS and payment adjustments• August 1st first notification

• 30 days to request recalculation

• Final report no later than November 1, 2017

• Annual quality performance reports will be made publically available

Performance Reporting

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Notable Answers:

• Information about the measures utilized in the first year of the HHVBP Model, including the measure specifications for the coordination of care and prior functioning measures will be presented during a webinar tentatively scheduled for January 2016.

• OASIS-based measures are calculated using assessments from the OASIS assessments from Medicare FFS, Medicare Advantage, Medicaid FFS, and Medicaid Managed care.

• All Medicare certified agencies in the 9 states are required to participate, even those with as few as 10 cases/year.

• CMS is compiling aggregate benchmark and achievement thresholds based on 2013 and 2014 data. Only the aggregate level Benchmarks and Achievement thresholds (by state and by cohort size) will be calculated using the 2013 and 2014 data.

CMS Q&A’s – Dec 2015

Source: https://innovation.cms.gov/initiatives/Home-Health-Value-Based-Purchasing-Model/faq.html

• HHVBP Connect: An interactive platform to learn more about the Model and collaborate with other HHAs• Find the latest updates for the HHVBP Model

• Download valuable resources to help you succeed in HHVBP

• View upcoming HHVBP events and key Model milestones

• Sole source for event registration

• Share best practices and “chat” with your colleagues in the nine Model states

• HHVBP Secure Portal• Where HHAs will submit data on new measures

• Where HHAs will retrieve quarterly and annual reports

HHVBP Connect Site

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• HHVBP Connect Site – Landing Page

HHVBP Connect Site – Landing Page

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HHVBP Base Line and Performance Periods

HHVBP Baseline and Performance Periods

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What can we learn about this implementation?

• Has changed over time – The number of measures and domains have changed in each of the last 3 years since it’s inception, including Domain weighting

• HCAHPS also includes points for consistency if better than the 50th percentile in each of the Patient Experience dimensions

• The Bonus or Penalty is netted against the withholds in each year limiting the impacts on cash flow

• Unlike the Home Health Proposal, the Base year for Hospitals change every year by one year

Hospital Value Based Purchasing (HVBP)

• Measures and Domains

Hospital Value Based Purchasing (HVBP) (cont.)

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• Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program

• Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement

• Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP

Learning Objectives

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Total Performance Scoring

• CMS proposing that TPS and payment adjustments would be calculated based on an HHA’s CCN and therefore, based only on services provided in the selected states

• 21 OASIS/HHCAHPS/Claims based measures will be used in the TPS unless the an agency does not have 20 or more episodes per measure (Accounts for 90% of the score)

• Three New Measures will account for the 10% of the score

• If an HHA does not meet this threshold to generate scores on five or more of the Clinical Quality of Care, Outcome and Efficiency, and Person and Caregiver-Centered Experience measures, no payment adjustment will be made

• Total Performance Scoring (TPS) (cont.)

Total Performance Scoring (TPS) (cont.)

TPS Example (HHA 1)

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Scores on 16 available OASIS/HHCAHPS measures = 88 Points

• HHA 1’s total possible points would be calculated by multiplying the total number of measures for which the HHA reported on least 20 (twenty) episodes by the maximum number of points for those measures ten (10), yielding a total of 160 possible points

• 88 points divided by the total 160 = .55

• .55 points X 90 = 49.5

• New Measures – all three entered equals 30 points out of a maximum of 30 = 1.0 X 10 points = 10 points

• Total Points = 59.5

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Total Performance Scoring (TPS) (cont.)

• Each agency’s value-based incentive payment amount for a fiscal year will depend on:

• Range and distribution of agency total performance scores

• Amount of agency's base operating HHRG payment amount

• The value-based incentive payment amount for each agency will be applied as an adjustment to the base operating HHRG payment amount for each episode

Net Reimbursement Impacts

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• CMS will use a linear exchange function (LEF) to distribute the available amount of value-based incentive payments to agencies, based on agency’s total performance scores on the HHVBP measures

Value-Based Purchasing (HHVBP)

CMS HHVBP Impact Reporting

CMS HHVBP Impact Reporting

• Distribution of the Payment Adjustments in the different model years

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CMS HHVBP Impact Reporting (cont.)

CMS HHVBP Impact Reporting (cont.)

Example of HHA Large Cohort Payment Adjustments

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LEF Distribution Examples

LEF Distribution Examples

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• LEF Distribution Examples (cont.)

LEF Distribution Examples (cont.)

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• LEF Distribution Examples (cont.)

LEF Distribution Examples (cont.)

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LEF Distribution Examples (cont.)

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LEF Distribution Examples (cont.)

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Create Financial Baseline

• Meet with Operations and Quality to determine first pass at “what if” criteria for change on each measure.

• Using TPS computed, work through calculations in the Linear Exchange function to determine financial impact/risk for this first pass of assumptions.

• Create variation examples within each domain and across domains taking into consideration clinical team variation in scoring, resources needs ~ what’s a “heavy lift” and areas needing immediate or critical focus for the organization.

• Develop a table of each iteration recording results on assumptions on each measure, TPS and related financial impact. Share results with Operations and Quality team to help focus initiatives.

• Develop or obtain a tool to organize data for easy reference to domain, measure, data sources etc.

• Verify data from all sources

• Insert proxy data for any missing variables

• Achievement, Threshold and Benchmark will change as all agencies innovate for improvement

The Foundation of Analysis is Accurate Data

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Measure Threshold Benchmark What ifAchv.

Pts.

Imprv.

Pts.Final Pts.

87.0 86.0 91.0 88.0 4.100 2.000 4.100

85.0 85.0 93.0 86.0 1.625 0.750 1.625

85.0 85.0 93.4 86.0 1.571 0.690 1.571

79.0 83.0 93.7 80.0 - 0.180 0.180

Financial Risk Estimates - PHH

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AgencyMedicare

Budget

Payment Adjustment Distribution

Estimated Payment Adjustment

if TPS = 35 If TPS = 55 If TPS = 75

CY2016 $63,432,660 3% ($342,436) $190,298 $922,945

CY2017 $66,604,294 5% ($589,448) $329,691 $1,605,163

CY2018 $69,934,508 6% ($755,293) $419,607 $2,035,094

Estimated TPS Distribution for Agency Cohort

10 20 30 40 50 60 70 80 90 100

*actual adjustment % will change with cohort distribution and annual % distribution

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• Identify the components to Home Health Value Based Purchasing (HHVBP) defined in the Final Rule as well as lessons learned from the Hospital VBP program

• Illustrate the methodology for the calculating the Total Performance Score (TPS) and how to understand the current ratings and planning for improvement

• Identify the actions one agency addressed in operational and workflow considerations to be successful under HHVBP

Learning Objectives

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Government payers payment reform and quality timeline

10/1/2012: Value Based Purchasing (VBP) begins; Readmissions Penalty begins

10/1/2014: Hospital Acquired Conditions penalty begins 1/1/2015: Physician Value-Based Payment Modifier 3/2015: Next Generation ACO announced SGR repeal ties a greater share of physician payment to quality

10/1/2007: Pay for Performance begins

10/1/2011: Readmissions Penalty begins Health Policy Commission material changes/market reviews

• 1.0% VBP withhold

• 1.0% max readmission penalty

• 1.25% VBP withhold

• 2.0% max readmission penalty

• 1.5% VBP withhold

• Addition of VBP Efficiency Domain

• 3.0% max readmission penalty onwards

• Physician Value Based Payment Modifier in effect for some MDs

• 1.75% VBP withhold

• Medicaid F2F• HHVBP• IMPACT Act• Discharge COP

• 2.0% VBP withhold onwards

• Physician Value Based Payment Modifier in effect for all MDs

Goal of 50% of Medicare payments in alternative payment and/or population based payment by 2018

Site Neutral Payments (IP/OP; LTCH/IRF/SNF)

Short Stay payment reform Home Health Quality

Improvement Program Expansion of Shared Savings &

Bundled Payment Programs Expansion of quality measure

set for VBP, readmissions, HAC, inpatient psych, ESRD, condition specific Medicare Spending Per Beneficiary, etc

1/1/2012: Pioneer ACO and Medicare Shared Savings Programs begin; ESRD Quality Incentive Program begins; e-prescribing mandatory for MD’s

10/1/2013: Inpatient Psych Quality Reporting Program begins; Quality reporting for LTCHs and Inpatient Rehab Facilities begins

Phase I of Bundled Payments for Care Improvement Program begins July 2014: IOM Committee on GME Reform Report is published

10/1/2013: Primary Care Payment Reform Initiative (PCPRI) MassHealth ACO Request for Information Insurer calculation of enrollee out of pocket liability by provider

PCPRI: PMPM payment for PCP Services• Payment adjusted for quality • Shared Savings/Risk (optional) on total spend

Cost Trend Hearings TME / Relative Price Reporting

Increased oversight of insurance market

Continued expansion of quality measure set for P4P

Cap TME growth Medicaid inpatient psych bundled payment proposal MassHealth announced stakeholder sessions aimed at improvements /

new payment models; Downing Bill introduced

Federal FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 [Future]

Care initiative for dual Medicare/Medicaid beneficiaries 1/1/2013: Mandate to increase penetration of alternate

payments from 25% to 80% by 1/1/15

1/1/2011: Center for Medicare & Medicaid Innovation (CMMI) established

State FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 [Future]

3/2010: Passage of Affordable Care Act

Increasing Velocity of Change

Value-Based What? Our first reaction…

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Please make it go away!

Value-Based What? Our second reaction…

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What me worry?

Value-Based What? Our third reaction…

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Goal is to synergize efforts

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… while not muddling priorities and overcomplicating (e.g., case conferencing)

Action step sequence for PHH

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• Where are our agency’s scores in relation to our stateaverages?

• Have we chosen the right comparison group?

• How have our quality and satisfaction scores improved over time?

• How does our Quality of Patient Care Star Rating compare to our state’s star ratings?

• Where do we have the best opportunity to improve our scores:– Process measures, Outcomes, HHCAHPs?

• Begin to drill down…

Take Stock of your Scores and PI Programs

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How does Massachusetts compare to the Nation?

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State

Nation

Outcomes Measures

• VBP Measures National vs. Massachusetts

VBP Measures National vs. Massachusetts

Source: HHC Scores Posted October 201552

Partners HealthCare at Home Outcomes 5 Star

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Focus Areas

• Improvement in Pain

• Drug Education

• Flu Vaccine

• 60 Day Hospitalization

Partners HealthCare at Home HHCAHPs 5 Star

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High Level Strategies

• ‘It takes a village’ – Improvement is everyone’s job

• Focus and data must be at the Team and Clinician Level

• Choose the highest bar (State, National, SHP) as your benchmark

• For Dashboards - Use ‘stoplight’ color coding with goal to ‘Get the Red Out’ – simplify reporting for impact

• Use Innovative Visuals like Tornado charts to drive home points like ‘Rate of Improvement’

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Different Benchmarks for HHVBP and 5 STAR

Different benchmarks yield Different pictures

Compared to CMS National

Compared to SHP State

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VBP/5-Star Rate of Improvement

Tornado Chart shows Rate of Improvement

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-8.00 -6.00 -4.00 -2.00 0.00 2.00 4.00 6.00 8.00 10.00

Ambulation

Bed Transfer

Bathing

Pain Interfering w/ Activity

Dyspnea

Timely Initiation of Care

Drug Education All mEds in Short Tem EOC

Management of Oral Meds

Flu Vaccine Received - Current Season

PPV Received - Ever

Composite 1: Care of Patients

Composite 2: Comm Between Providers & Patients

Composite 3: Specific Care Issues

Universal 1: Gave the HHA a score of 9 or 10

Universal 2: Would recommend the HHA

0.20

0.40

-0.20

0.80

0.90

-1.70

0.90

0.70

-4.70

9.40

2.30

0.40

3.20

-0.20

0.50

0.30

0.60

0.30

0.30

0.30

0.10

0.30

0.50

-2.10

-0.80

0.00

0.00

1.00

1.00

0.00

2.10

3.90

2.20

2.00

2.20

0.50

1.20

4.00

-6.20

0.40

-0.40

-0.20

0.10

-0.40

-0.80

PHH Rate

StateCMS Rate

State SHPRate

• Clinical Managers, Quality, OASIS review and education staff all work together as a team• Identify team/clinician specific opportunities for improvement

• Education at the team and clinician level

• Monitor progress and provide ongoing ‘real time’ feedback• Re-educate as needed but not in perpetuity

• Performance management is critical

• Focus on entire spectrum from OASIS competency through to clinical practice – offer “Competency Days”

• Celebrate Improvements big and small

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Education Strategies

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Outcomes Improvement vs Stabilizationat Team and Clinician level

Education Strategies Using Data

Patient level detail

Room for improvement on one specific measure…

Room for improvement for one specific patient…

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Education Strategies Using Data

HHCAHPs at Agency, Overall and Specific Question levelHH Provider

handled specific issues correctly

At SOC, did someone from agency talk with you about how to set up home?

About Rx and OTC?

Educational Approach

• OASIS Accuracy

• Skits/Videos demonstrating the ‘right’ and ‘wrong’ way to assess

• Home Care Institute ‘Room by Room’

• Fazzi ‘OASIS Walk’

• Improvement Concepts

• Improvement vs Stabilization

• Use of Dashboards and Tornado Graphs

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• Care Planning and Goals

• InterprofessionalCollaboration

• Regular Case Conferencing

• Real Time Feedback from OASIS Reviewers

• Focus Topics

• Adding full-time resource to bridge between Quality/Education and Clinical Operations - based in Ops

• Help convert analysis, findings, strategies to action

• Help de-clutter multitude of priorities

• Support accountability orientation

Evaluating

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ROI is compelling

Role tension

Re-assess as you go….

• Run quarterly sensitivity analysis and develop quarterly review sessions.

• As all HHA’s innovate to improve, the calculations remain dynamic.

• Check with corporate office concerning accounting ~ many hospital systems have experience and have developed standards for i.e. reserves for VBP and the associated timing. This could potentially play a role in future budget processes.

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• Synergize efforts where possible (case conference should be targeted; multiple birds… one rock)• Culture change• Influence/change clinician

behavior; performance management

• Management discipline

• Convert analysis to action• Clinical managers need

specific strategies to work with individual staff

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Lessons learned

• Reduce variation to allow for broader interventions

• Set it and forget it… NOT. Quarterly assessment meetings (iterative and learning process)

• Properly reserve so no P&L ‘surprises’

• Work with IT vendor (on new measures); start early as not all are preparing

Questions & Answers

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Contact Information

Chris AttayaVP of Business IntelligenceStrategic Healthcare Programs (SHP)cattaya@shpdata.comMain: 805-963-9446Cell: 617-962-6950

Rey SpadoniPresidentPartners HealthCare at Homerspadoni@partners.orgDirect: 781-290-4060