Value Based Purchasing Gary Swartz, JD, MPA Associate
Value Based Purchasing Gary Swartz, JD, MPA Associate Executive Director American Academy of Home Care Medicine AAHCM Value Based Purchasing (VBP) Context and history VBP and risk adjustment (RA) defined
VBP w RA embedded across public and private models Academy advocacy to assure accurate risk adjustment for your HBPC population; request for your help VBP with RA provides HBPC professional services and organizational leadership opportunities AAHCM Value Based Payment - Context Siloed care has been supported by 1960s Medicare
insurance program Fragmented care, payment and professional silos and communication barriers Medical care/Medicare cost increases Legislative; Patient Protection and Affordable Care Act and BBA (1997) for Medicare Advantage
Risk adjustment and value based purchasing AAHCM Siloed Medicare by Payments 2013 AAHCM Medicare program cost continues to increase 2010 Patient Protection and Affordable Care Act Value-Based Purchasing Provisions Type of Value-Based Purchasing Program VBPP and Setting Timeline
Hospital Value-Based Purchasing Program October 1, 2012 (current program) Physicians (or groups of physicians) under Physician ValueBased Payment Modifier January 1, 2015, for a subset of physicians January 1, 2018, for all physicians (program to be implemented) Inpatient critical access hospitals No later than 2 years after date of act (May 1, 2010 - demo.) Hospitals excluded from HVBP due to insufficient numbers No later than 2 years after date of act (May 1, 2010) demo.) Long-term care hospitals
No later than January 1, 2016 (pilot program) Hospice programs No later than January 1, 2016 (pilot program) Psychiatric hospitals No later than January 1, 2016 (pilot program) Rehabilitation hospitals No later than January 1, 2016 (pilot program) PPS-exempt cancer hospitals No later than January 1, 2016 (pilot program)
Ambulatory surgical centers Submit plan to Congress no later than January 1, 2011 (plan for program) Home health agencies Submit plan to Congress no later than October 1, 2011 (plan for program) Skilled nursing facilities Submit plan to Congress no later than October 1, 2011 (plan for program) Shared Savings ACOs no later than January 1, 2012 (current program) Bundled Payment Hospital/physicians/post-acute care
no later than January 1, 2012(demonstration program) Legislative provisions for VBP now cover the range of program benefits MD, NP, PA and others Hospitals Ambulatory settings
CMS Innovation Center (ACOs, Shared savings) Post Acute IMPACT Act BACPAC (proposed) AAHCM Provisions include common elements across providers and care settings
Mix of payment method and model change Measures based data development for payment and reporting Public reporting/transparency Compare programs; Stars Ratings AAHCM What Is Value? Value = Quality Cost
AAHCM Value-based purchasing concepts Agency for Healthcare Research and Quality (AHRQ) Business Group on Health Buyers hold providers accountable for cost and quality Demand side strategy to measure, report, and reward excellence in health care delivery.
Information on quality, outcomes, health status (measure development) Reduce inappropriate care Identify and reward best performers Actions of coalitions, employer purchasers, public sector purchasers, health plans, and individual consumers in making decisions that take into consideration access, price, quality, efficiency, and alignment of incentives. Effective health care services and high performing are rewarded with
improved reputations through public reporting, enhanced payments and DHHS announcement of transition from FFS to Value Based Payment will increase importance of risk adjusted VBP methodologies Percent of payment in quality/value based models DHHS/Private Payors (HCTTF) announcement February, 2015 Risk adjustment is now embedded across Medicare and private plans AAHCM Physician diagnostic coding drives
risk adjustment and thus payment AAHCM What is the Value-Based Payment Modifier (Value Modifier)? Provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished compared to the cost of care during a performance period
Value Modifier is an adjustment made on a per claim basis to Medicare payments for items and services under the Medicare PFS. AAHCM Value based payment concerns relate to risk adjustment TINs treating a large number of beneficiaries with multiple chronic conditions could perform worse on certain quality and
cost measures than TINs with relatively healthy beneficiaries due, at least in part, to differences in their beneficiary populations. AAHCM The role of risk adjustment Risk adjustment facilitates more accurate comparisons by accounting for differences in beneficiary case mix across TINs AAHCM
Risk adjustment A process of adjusting: health plan payments, or health care provider payments, or premiums to reflect the health status of beneficiaries or plan members AAHCM Risk Adjustment Definition varies by the application across
Medicare payment models Risk score of 1.0 corresponds to average expected expenditure; higher risk scores are associated with higher expected expenditures The right risk adjuster is critical AAHCM Changes to Medicare Fee Schedule due to Medicare Access and CHIP Reauthorization Act (MACRA)
Year Medicare Fee Schedule 2015 -2019 .5% increase each year 2019- 2025 2019 rates plus ability to receive additional payment through Merit-Based Incentive Payment System (MIPS) 2019 -2024 5% bonus for those participation in
qualified alternative payment models AAHCM MIPS - Not Your Fathers Value Based Payment Modifier or is it? AAHCM MIPS - four categories and bonus or reduce MFS paymentbased on composite performance Quality 30 percent Measures used in the existing quality performance programs (PQRS, VBM, EHR MU), Secretary to solicit recommended measures
Resource Use Measures used by qualified clinical data registries Measures used in the current VBPM program 30 percent Additional process to report specific role in treating the beneficiary Meaningful Use Research on how to improve risk adjustment to ensure professionals are not penalized for serving sicker or more costly patients Current EHR Meaningful Use requirements, demonstrated by use of a certified system
15 percent Clinical Practice Improvement Activities 25 percent Professionals who report quality measures through certified EHR systems for the MIPS quality category are deemed to meet the meaningful use clinical quality measure component Professionals will be assessed on their effort to engage in clinical practice improvement activities. Activities must be applicable to all specialties and attainable for small practices and professionals in rural and underserved areas How much can payment be reduced under MIPS? Year
2019 2020 2021 2022 and after Potential reduction minus 4 percent minus 5 percent minus 7 percent minus 9 percent AAHCM The path to value based purchasing and population health management begins with accurate risk adjustment AAHCM
Academy advocacy to assure accurate risk adjustment and payment for your HBPC population; request for your help Academy is conducting analysis using 2012 Medicare data to document the inadequacies of current risk adjustment and to present to CMS Practice TINs and NPIs are required to associate claims data to document the inadequacies of current risk adjustment models; in the absence of improvement to the risk adjustment practices will appear less cost effective and be penalized Send
your TINs and NPIs to Gary Swartz Results of analysis will be presented to CMS to modify risk adjustment Protects your revenue in the future under VBPM and MIPS Protects access to care for your patients and practice revenue under APMs/ACOs/bundles application to private health plans Contributes
to the development of payment policy for the frail elderly AAHCM There is danger; what are the opportunities? AAHCM Professional HBPC services and organizational opportunities AAHCM
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