How Health Plans, Employers, and Providers Improve Care, Efficiency and

Revenue with Value-Based Care

Rodrigo Giacinti, MHAMarket Manager West Operations

Rodrigo Giacinti, MHAMarket Manager West Operations

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OutlineThe Evolution of Bundled Payment Programs

Episodic Management Tools and Interventions

BPCI Advanced• Pricing• Trumping• Advanced APM •New Bundles• Timeline• Application deadline

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BPCI Advanced Enhancements

The Evolution of Bundled Payment Programs BPCI Advanced aims to build upon knowledge gained under the legacy BPCI program to further improve the efficiency and quality of care for patients.

Legacy BPCI Program Carryover

Advanced APM status under MACRA

Continued voluntary participation

Simplified precedence rules

Hospital setting triggered

Increased ACH/PGP engagement with specialists

DRGs collapsed into clinical bundles

New bundles including 3 outpatient episodes

Risk-adjusted prospective pricing

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Quality-based performance measures

Single payment linking services in

a 90-day period

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Episodic Management Tools and Interventions

Identify patient

Determine Risk

Utilize NSOC decision-

support tools

Discuss post-acute options w/

patient

Coordinated hand-off to post-acute

facilityOptimize

post-acute length of stay

Continuously evaluate discharge options

Post-acute Care Setting

Discharge patient to

appropriate setting

Monitor patient

progress

Primary Care Physician follow up

Home

Discharge to appropriate site of care within PN*

Acute Setting

A variety of tools and services are needed to improve performance and care delivery throughout an episode continuum.

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BPCI Advanced: Episodes, Selection and Trumping

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82%

9029 Clinical Episodes (“bundles”) triggered by an inpatient “Anchor Stay” covering 105 MS-DRG

3 outpatient bundles “Anchor Procedures” triggered by 29 HCPCS codes

The 28 Clinical Episodes that continue from the existing BPCI program represent 82% of Remedy Partners Model 2 business (in terms of program size)

Episode duration is 90 days

1st No risk track selection: Winsorization set at the 1st / 99th percentile

Program will not utilize any time-

based precedence rules

Hospitals participating in CJR will not be permitted

to select lower joints

Episodes will include beneficiaries that align with

MSSP track 1, 1+ & 2, but exclude Next Gen ACOs

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Bundles29 Inpatient Clinical Episodes 3 Outpatient Clinical EpisodesDisorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis - NEW Gastrointestinal obstruction Percutaneous coronary intervention (PCI)

Acute myocardial infarction Hip & femur procedures except major joint Cardiac defibrillator

Back & neck except spinal fusion Lower extremity/humerus procedure except hip, foot, femur Back & neck except spinal fusion

Cardiac arrhythmia Major bowel procedure

Cardiac defibrillator Major joint replacement of the lower extremity

Cardiac valve Major joint replacement of the upper extremity

Cellulitis Pacemaker

Cervical spinal fusion Percutaneous coronary intervention (PCI)

COPD, bronchitis, asthma Renal failure

Combined anterior posterior spinal fusion Sepsis

Congestive heart failure Simple pneumonia and respiratory infections

Coronary artery bypass graft Spinal fusion (non-cervical)

Double joint replacement of the lower extremity Stroke

Fractures of the femur and hip or pelvis Urinary tract infection

Gastrointestinal hemorrhage

BPCI Advanced: Reconciliation, Financial Arrangements & Pricing

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Reconciliation• Semi-annual reconciliation• Payments can be reduced by 10%

based on adherence to quality measures• Quality data mined by CMS for first

two years, reporting requirements for participants begin in 2020

Financial Arrangements• 50% cap will apply to NPRA Sharing partners

(“gainsharers”)• NPRA sharing partners must participate in

activities specified by CMS

ØPricing based on four year historical period from 2013-2016.

ØThe price for each bundle will be set prior to the beginning of each performance year.

ØCMS will build in a 3% discount into the pricing model.

Ø The price will be specific to the facility participant or the facility in which the Participant treats patients.

Pricing

New Quality MeasuresCMS is prescribing quality measures for BPCI Advanced.

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1 Commencing 10/1/2018, compliance with quality measures will be scored

2 Score will be calculated for each measure by bundle and then aggregated across all bundles for each Episode Initiator

3 Scores will be weighted for outcome measures and process measures resulting in a Composite Quality Score which will serve as adjustment mechanism for Net Payment Reconciliation Amount

4 For first two years, CMS will automatically collect quality data from claims; no additional administrative burden placed on participants

5 For first two model years, adjustment of total reconciliation amount (positive or negative) is capped at 10% based on Composite Quality Score

6 Commencing in 2020, additional measures may require tracking

New Quality MeasuresCMS is prescribing quality measures for BPCI Advanced.

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All-cause Hospital Readmissions Measure (NQF #1789) all clinical episodes

Advance Care Plan (NQF #0326) all clinical episodes

Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)

select episodes

Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)

select episodes

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)

select episodes

Excess Days in Acute Care after for Acute Hospitalization Myocardial Infarction (NQF #2881) select episodes

AHRQ Patient Safety Indicators (PSI 90) select episodes

What is an Advanced Alternative Payment Model?Alternative payment model (APM): a payment approach that rewards providers for delivering high-quality and cost-efficient care.

Advanced APMs: a subset of APMs that let practices earn more rewards in exchange for taking on risk related to patient outcomes.

Exempt from MIPS penalties and quality reporting if meet volume thresholds

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To Qualify, You Must:Use Certified EHR TechnologyBear > nominal risk (8% revenue)Base payment on quality measures comp. to MIPS

Examples of Advanced APMs:BPCI AdvancedMSSP Track 2 or 3 ACOCPC+OCM 2-sided riskComprehensive ESRDNextGen ACOCJR CEHRT Track

© 2018 Remedy Partners, Inc. All Rights Reserved.

What is a Qualifying APM Participant (QP)?

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Must achieve threshold for Patients or Spending in an Advanced APM

Must exceed revenue or patient count thresholds

For 2019: 50% Medicare Part B payments or 35% Medicare Part B patients in AAPM

For 2023: 75% payments or 50% patients

© 2018 Remedy Partners, Inc. All Rights Reserved.

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Timeline

BPCI Advanced: First Quality Payment Program Impact in 2019

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Data Submission Deadlines

March 2020

Performance Period EndsDec 2019

QPP Performance Period

Jan 2019

Payment Adjustments

Jan 2021

Thank you!

Rodrigo Giacinti, MHA

Email: rgiacinti@remedypartners.com

Phone: (573) 310-1485

www.remedypartners.com

BPCIRemedy’s Experience in Arizona

Rodrigo GiacintiMarket Manager, West Operations

Remedy Partners

Our History in Arizona

• Remedy Partners was founded in 2011 by Steve Wiggins. In 2013 our first partner goes live

• In 2015 Remedy becomes the Convener for one of the largest PGP company in the nation

• In 2017 Remedy’s Partner Services division begins the development/execution of the Post Acute Strategy in AZ

Arizona by the BPCI numbers• Our primary partner in AZ is a PGP with 5 Episode Initiators• 1,551 Episodes Initiated over the last year• 17 Bundles or 53 MS-DRG (2 ortho bundles)

AMI ATHEROSCLEROSIS CABG CELLULITIS

COPD DIABETES EGODD GI HEMM

GI OBSTRUCT HIP AND FEMUR E/MJ LEHP MPVD

RED BLOOD CELL DISORDERS RENAL FALURE SEPSIS SIMPLE PNEUMONIA

TRANSIENT ISCHEMIA

Key Lever Management• Post Acute Care Performance Management Networks

– SNF and HHA networks created for each site– Networks are intended for all patient population (not just BPCI)– Qualitative and Quantitative selection process (Bi-annual revision) using our analytic

shop and tools• Appropriate NSOC

– Select the appropriate setting with our CARL (Care at the Right Location) decision support mechanism

– Interdisciplinary approach• Readmission Reduction

– Leverage our Episode Connect technology to track VBC patients for the duration of the episode

– Partner with strong downstream providers to maximize patient care experience

Leverage Technology…. Episode Connect• Episode Connect connects administrators, nurses, physicians,

nurses, patients and families

Challenges

• Cooperation between stakeholders (Hospital, SNF, HHA, other)• Technology Adoption (Episode Connect) for

downstream providers• Downstream provider education and buy in on the BPCI

program• Homeless and Behavioral patients

Successes over the last year

• Increased Home Health Utilization from 4% (Adj Hist) to 13.7%

• Decreased readmission from 60.7% (Adj Hist) to 36%

• Decreased SNF LOS from 37 days (Adj Hist) to 25 days

• Created 5 High Quality SNF and HHA networks

• Developed great partnerships with Downstream providers

Adjusted Historic – Claims occurring between July 2009 and June 2012Current Period – Claims occurring between 2016Q4 and 2017Q3

Lessons to Share • As an awardee Convener, we are able to bring the combined

experience of 800+ providers nation wide and share best practices across all partners. Healthcare is local, and we must tailor the plan according to the market needs

• Partner Services is composed of hundreds of professionals that can use Big Data to generate next steps and insights.

• Program Design and Administration is key. Having a dependable back office that can take care of the program while you can focus on the #1 priority, the patient!

• BPCI is the beginning of payment reform. Payers, employers, and patients will soon follow

Thank you!

Rodrigo Giacintirgiacinti@remedypartners.com

(573) 310-1485