Evaluation and Monitoring of the Bundled Payments for Care Improvement Model 1 Initiative
Bundled Payments for Care Improvement Advanced · Bundled Payments for Care Improvement Advanced...
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www.datagen.info ® © 2018 DataGen. May not be reproduced or distributed without prior written permission. Alyssa Dahl Manager, Healthcare Data Analytics DataGen Bundled Payments for Care Improvement Advanced Slide 1 4/25/2018
Transcript of Bundled Payments for Care Improvement Advanced · Bundled Payments for Care Improvement Advanced...
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Alyssa DahlManager, Healthcare Data AnalyticsDataGen
Bundled Payments for Care Improvement Advanced
Slide 14/25/2018
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Medicare BPCI AdvancedThe Basics
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BPCI Advanced• Voluntary Model• A single retrospective
bundled payment and one risk track, with a 90-day Clinical Episode duration
• 29 Inpatient Clinical Episodes
• 3 Outpatient Clinical Episodes
• Qualifies as an Advanced APM
• Applications were due 3/12/2018
• Performance year begins 10/1/2018
• Hospitals with <40 clinical episodes in baseline period cannot participate
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https://innovation.cms.gov/initiatives/bpci-advanced/
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Convener vs. Episode Initiator
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• Hospital or Physician Group Practice (PGP) that triggers the clinical episode
Episode Initiator (EI)
• Hospital or PGP episode initiator that bears risk for itself
Non-Convener Participant
• Takes risk for an EI or group of EIs• Can be anyone including hospitals or a
hospital system
Convener Participant
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Episode Triggers
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Inpatient Clinical Episodes
• Anchor Stay• Inpatient
admissions identified by MS-DRG
Outpatient Clinical
Episodes• Anchor Procedure• Outpatient
procedure identified by HCPCS code
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Inpatient Clinical Episodes• Acute myocardial infarction• Back & neck except spinal
fusion• Cardiac arrhythmia• Cardiac defibrillator• Cardiac valve• Cellulitis• Cervical spinal fusion• COPD, bronchitis, asthma• Combined anterior posterior
spinal fusion
• Combined anterior posterior spinal fusion
• Congestive heart failure• Coronary artery bypass graft• Disorders of the liver excluding
malignancy, cirrhosis, alcoholic hepatitis*
• Double joint replacement of the lower extremity
• Fractures of the femur and hip or pelvis
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Inpatient Clinical Episodes• Gastrointestinal hemorrhage• Hip & femur procedures except
major joint• Lower extremity/humerus
procedure except hip, foot, femur
• Major bowel procedure• Major joint replacement of the
lower extremity• Major joint replacement of the
upper extremity
• Pacemaker• Percutaneous coronary
intervention• Renal failure• Sepsis• Simple pneumonia and
respiratory infections• Spinal fusion (non-cervical)• Stroke• Urinary tract infection
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Outpatient Clinical Episodes• Percutaneous Coronary Intervention (PCI)• Cardiac Defibrillator• Back & Neck except Spinal Fusion
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Model Timeline
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Medicare BPCI AdvancedComparison to CJR
Slide 104/25/2018
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Commonalities
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Episode Length: Anchor + 90
Days
Covers Part A & B services,
including PAC and hospice
Retrospective Reconciliation
Quality Metrics Advanced APM Waivers
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Differences
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Category CJR BPCI AdvancedParticipation Mandatory for hospitals in
selected regionsVoluntary
Episode Initiators ACHs ACHs and PGPsPrecedence BPCI > CJR CJR > BPCI Advanced
AT PGP > OP PGP > ACH
Episode Selection 1 IP clinical episode with fracture stratification
29 IP and 3 OP clinical episodes
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Differences
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Category CJR BPCI AdvancedExcluded Services
• Blood clotting factors, tech payments, OPPs pass-thru payments.
• Certain Part B services.
• Blood clotting factors, tech payments, OPPs pass-thru payments.
Readmissions • Readmissions for 469/470 at same hospital cancel first episode.
• Readmission expenditures omitted for excluded MS-DRGs
• Readmissions for included MS-DRGs do not trigger new episodes.
• Readmission expenditures omitted for excluded MS-DRGs
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Differences
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Category CJR BPCI AdvancedCMS Discount 0.5%-3% (Based on QP) 3%Target Price Historic baseline
performance with gradual transition to regionally based target price
Historic baseline performance adjusted for patient case mix and peer group spending patterns
Reconciliation Annual Semi-AnnualStop Loss/Gain +/-10% Year 3
+/-20% Years 4-55% Rural Hospitals
+/- 20%
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Quality
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Measure ProgramHCAHPS Survey measure CJRHospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty
Both
Advanced Care Plan BPCI AdvancedAHRQ Patient Safety Indicators (PSI 90) BPCI AdvancedAll-cause Hospital Readmission Measure BPCI Advanced
Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
BPCI Advanced
Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft Surgery
BPCI Advanced
Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin
BPCI Advanced
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Medicare BPCI AdvancedTarget Price Structure
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Target Price Strategy• BPCI Advanced target price goals:
– Consideration towards historical efficiency– Reward improvement over time– Adjustment for patient case mix– Control for differences in spending trends by
region and hospital characteristics
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Patient Case Mix Adjusters
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Hierarchal Condition
Categories (HCCs)
Recent resource use Demographics
Long-term institutional
statusMS-DRG/APC
Other factors specific to
clinical episode category
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Peer Group Characteristics
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Academic Medical Centers
Urban/Rural Safety-Net Hospitals
Region(Census)
Bed Size
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Hospital Benchmark Price
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Standardized Baseline
Spending (SBS)
Peer Adjusted Trend (PAT)
Factor
Patient Case Mix Adjustment
(PCMA)
Hospital Benchmark
Price
• Standardized Baseline Spending (SBS)– Historical efficiency in the baseline period, risk and peer standardized
• Patient Case Mix Adjustment (PCMA)– Adjustment for patient case mix
• Peer Adjusted Trend (PAT) Factor– Adjustment for spending variation across and within peer groups– Trend adjustment from baseline period spending to Model Year
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Final Target Price
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Hospital Benchmark Price
Conversion to
“Real” Dollars
BPCI Advanced Discount
Factor(-3%)
Final Target Price
Update to Most
Recent Payment
Rates
Recalculated to account for PCMA in
performance year
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Reconciliation
Clinical Episode
Episode Count
(a)
Target Price per Episode
(b)
Total Target Amount
(a*b)
ActualEpisode
Expenditures
(c)
Reconciliation Amount[(a*b)-c]
CHF 100 $32,000 $3,200,000 $2,600,000 $600,000
COPD 60 $20,000 $1,200,000 $1,500,000 -$300,000
Positive Total Reconciliation Amount
150 $27,500 $4,400,000 $4,100,000 $300,000
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Hospital A
Positive Total Reconciliation
Amount
CQS Adjustment
Amount(Max = -10%)
NPRA Payment Amount
AdjustedPositive Total Reconciliation
Amount
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Reconciliation
Clinical Episode
Episode Count
(a)
Target Price per Episode
(b)
Total Target Amount
(a*b)
ActualEpisode
Expenditures
(c)
Reconciliation Amount[(a*b)-c]
CHF 80 $34,000 $2,720,000 $3,000,000 -$280,000
COPD 55 $18,000 $990,000 $975,000 $15,000
Negative Total Reconciliation Amount
135 $27,481 $3,710,000 $3,975,000 -$265,000
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Hospital B
Negative Total Reconciliation
Amount
CQS Adjustment
Amount(Max = +10%)
Repayment Amount
AdjustedNegative Total Reconciliation
Amount
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Medicare BPCI AdvancedEpisodes at a Glance
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Considerations for Episode Selection
• Clinical buy-in• Volume• Episode cost• Opportunity for savings• Distance from target
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Volume
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7.4%
5.2%
4.3%3.6%
3.3%
2.3%1.9%
1.4%0.6%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
10 20 30 40 50 100 150 300 500
Coe
ffici
ent o
f Var
iatio
n
Episode Count
Average Episode Cost Coefficient of Variation
40 clinical episode minimum to participate
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Episode Cost
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What are the cost drivers after discharge or outpatient procedure?
Can you do anything about it?
Costs = Medicare Payments.
Payments neutralized for provider specific adjustments to isolate utilization.
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Opportunity for Savings
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Type CHF CABG MJRLE PCIPost-Acute Care
30% 18% 35% 14%
Readmissions 25% 5% 5% 16%
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Episode Composition: MJRLE
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Episode Composition: CHF
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Episode Composition: CABG
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Episode Composition: PCI
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Distance from Target
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4%
5%
8%
5%
5%
4%
5%
0% 1% 2% 3% 4% 5% 6% 7% 8% 9%
Urinary Tract Infection
Sepsis
Percutaneous Coronary Intervention
Major Joint Replacements of the Lower…
Gastrointestinal Hemorrhage
Congestive Heart Failure
Cellulitis
Discount Reduction Needed
How much PAC spending would
you need to reduce to
recover the 3% discount?
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Outpatient Episodes
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Type B&N CD PCIPost-Acute Care
17% 3% 4%
Readmissions 9% 6% 13%
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Contact
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Alyssa Dahl, MPH CPH Manager, Healthcare Data
AnalyticsDataGen
(518) [email protected]
