cardiovascular market update 2018 - uk healthcare cecentral · congress passes macra. 1. to...
TRANSCRIPT
Cardiovascular Market Update 2018 Market Realities Impacting CV Service Line Strategy Prepared for UK HealthCare Gill Heart and Vascular Institute Network
Cardiovascular Roundtable
Megan Tooley Practice Manager Advisory Board Tooleymadvisorycom
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2
Objectives
- Review market dynamics and regulatory changes impacting CV providers and the delivery of cardiovascular care
- Discuss opportunities for performance improvement that should be evaluated as part of CV service line strategy
Educational NeedPractice Gap
- The complexity of an ever-changing health care market makes it challenging for CV programs to prioritize efforts often leading to a more narrow focus on individuals metrics versus a holistic focus on value across the continuum
Megan Tooley has nothing to disclose
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
3
What a Year and a Half itrsquos Been
Source Cardiovascular Roundtable research and analysis
1) American Health Care Act of 2017 Better Care Reconciliation Act Obamacare Repeal and Reconciliation Act 2) Episode Payment Models 3) Department of Health and Human Services
January 20 2017 President Trump sworn in makes health care top priority on Day 1
bull July 25-28 Senate votes down AHCA BCRA ORRA1
bull September 26 Senate cancels vote on Cassidy-Graham
Key Milestones in Recent Health Care Agenda
New President of the United States
Attempts to Repeal Replace the ACA
Mandatory Cardiac Bundles Cancelled
November 30 CMS cancels mandatory CABG AMI EPMs2
New HHS3 Secretary
January 24 Alex Azar confirmed as HHS Secretary following resignation of Tom Price
MedPAC Weighs in on MACRA
January 11 2018 MedPAC asks Congress to replace MIPS with voluntary value program faces pushback
BPCI Advanced Applications Due
March 12 CMS opens new voluntary bundled payment model
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4
Raising Questions About the Future of Riskhellip hellipBut Despite Uncertainty Payment Reform Will Remain in Some Form
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Cardiovascular Roundtable interviews and analysis
1) Centers for Medicare and Medicaid Innovation 2) Medicare Access and CHIP Re-Authorization Act
Key Questions from CV Leaders
How will the new administration impact MACRA2 implementation
Will the new administration migrate away from payment transformation
How will CMS prioritize value-based initiatives moving forward
What is the future of CMMI1 and care transformation programs (eg ACOs)
Many Reasons to Bet on the Future of Payment and Care Delivery Reform
Strong bipartisan support for the concept of payment reform
Near-unanimous bipartisan support for MACRA legislation
CMS Administrator Seema Verma has confirmed continued support for value-based care
Current administration committed to testing new models to deliver and pay for health care through CMMI
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
5
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
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6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
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7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
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14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
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15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
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16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
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17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
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18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
2
Objectives
- Review market dynamics and regulatory changes impacting CV providers and the delivery of cardiovascular care
- Discuss opportunities for performance improvement that should be evaluated as part of CV service line strategy
Educational NeedPractice Gap
- The complexity of an ever-changing health care market makes it challenging for CV programs to prioritize efforts often leading to a more narrow focus on individuals metrics versus a holistic focus on value across the continuum
Megan Tooley has nothing to disclose
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
3
What a Year and a Half itrsquos Been
Source Cardiovascular Roundtable research and analysis
1) American Health Care Act of 2017 Better Care Reconciliation Act Obamacare Repeal and Reconciliation Act 2) Episode Payment Models 3) Department of Health and Human Services
January 20 2017 President Trump sworn in makes health care top priority on Day 1
bull July 25-28 Senate votes down AHCA BCRA ORRA1
bull September 26 Senate cancels vote on Cassidy-Graham
Key Milestones in Recent Health Care Agenda
New President of the United States
Attempts to Repeal Replace the ACA
Mandatory Cardiac Bundles Cancelled
November 30 CMS cancels mandatory CABG AMI EPMs2
New HHS3 Secretary
January 24 Alex Azar confirmed as HHS Secretary following resignation of Tom Price
MedPAC Weighs in on MACRA
January 11 2018 MedPAC asks Congress to replace MIPS with voluntary value program faces pushback
BPCI Advanced Applications Due
March 12 CMS opens new voluntary bundled payment model
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
4
Raising Questions About the Future of Riskhellip hellipBut Despite Uncertainty Payment Reform Will Remain in Some Form
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Cardiovascular Roundtable interviews and analysis
1) Centers for Medicare and Medicaid Innovation 2) Medicare Access and CHIP Re-Authorization Act
Key Questions from CV Leaders
How will the new administration impact MACRA2 implementation
Will the new administration migrate away from payment transformation
How will CMS prioritize value-based initiatives moving forward
What is the future of CMMI1 and care transformation programs (eg ACOs)
Many Reasons to Bet on the Future of Payment and Care Delivery Reform
Strong bipartisan support for the concept of payment reform
Near-unanimous bipartisan support for MACRA legislation
CMS Administrator Seema Verma has confirmed continued support for value-based care
Current administration committed to testing new models to deliver and pay for health care through CMMI
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
5
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
3
What a Year and a Half itrsquos Been
Source Cardiovascular Roundtable research and analysis
1) American Health Care Act of 2017 Better Care Reconciliation Act Obamacare Repeal and Reconciliation Act 2) Episode Payment Models 3) Department of Health and Human Services
January 20 2017 President Trump sworn in makes health care top priority on Day 1
bull July 25-28 Senate votes down AHCA BCRA ORRA1
bull September 26 Senate cancels vote on Cassidy-Graham
Key Milestones in Recent Health Care Agenda
New President of the United States
Attempts to Repeal Replace the ACA
Mandatory Cardiac Bundles Cancelled
November 30 CMS cancels mandatory CABG AMI EPMs2
New HHS3 Secretary
January 24 Alex Azar confirmed as HHS Secretary following resignation of Tom Price
MedPAC Weighs in on MACRA
January 11 2018 MedPAC asks Congress to replace MIPS with voluntary value program faces pushback
BPCI Advanced Applications Due
March 12 CMS opens new voluntary bundled payment model
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
4
Raising Questions About the Future of Riskhellip hellipBut Despite Uncertainty Payment Reform Will Remain in Some Form
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Cardiovascular Roundtable interviews and analysis
1) Centers for Medicare and Medicaid Innovation 2) Medicare Access and CHIP Re-Authorization Act
Key Questions from CV Leaders
How will the new administration impact MACRA2 implementation
Will the new administration migrate away from payment transformation
How will CMS prioritize value-based initiatives moving forward
What is the future of CMMI1 and care transformation programs (eg ACOs)
Many Reasons to Bet on the Future of Payment and Care Delivery Reform
Strong bipartisan support for the concept of payment reform
Near-unanimous bipartisan support for MACRA legislation
CMS Administrator Seema Verma has confirmed continued support for value-based care
Current administration committed to testing new models to deliver and pay for health care through CMMI
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
5
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
4
Raising Questions About the Future of Riskhellip hellipBut Despite Uncertainty Payment Reform Will Remain in Some Form
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Cardiovascular Roundtable interviews and analysis
1) Centers for Medicare and Medicaid Innovation 2) Medicare Access and CHIP Re-Authorization Act
Key Questions from CV Leaders
How will the new administration impact MACRA2 implementation
Will the new administration migrate away from payment transformation
How will CMS prioritize value-based initiatives moving forward
What is the future of CMMI1 and care transformation programs (eg ACOs)
Many Reasons to Bet on the Future of Payment and Care Delivery Reform
Strong bipartisan support for the concept of payment reform
Near-unanimous bipartisan support for MACRA legislation
CMS Administrator Seema Verma has confirmed continued support for value-based care
Current administration committed to testing new models to deliver and pay for health care through CMMI
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
5
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
5
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
6
Guess Whatrsquos Not Getting Repealed Even If ACA Repealed Majority of Obama-Era Cuts Would Have Remained
1 Margin pressure will only intensify for CV
Source CBO ldquoBudgetary and Economic Effects of Repealing the Affordable Care Actrdquo June 2015 CBO ldquoLetter to the Honorable John Boehner Providing an Estimate for HR 6079 The Repeal of Obamacare Actrdquo July 24 2012 CBO ldquoCost Estimate and Supplemental Analyses for HR 2 the Medicare Access and CHIP Reauthorization Act of 2015 Budget of the United States Government (Proposed) FY 2016 Cardiovascular Roundtable research and analysis
1) Calculation includes ACA Inpatient Prospective Payment System Update Adjustments ACA Disproportionate Share Hospital payment cuts MACRA Inpatient Prospective Payment System update adjustments
ldquoProductivityrdquo Adjustments and Other Cuts to Reimbursement1 2017 2018 2019 2020 2021 2022 2023 2024 2025
($32B) ($48B)
($60B) ($71B)
($82B) ($94B)
($103B) ($116B)
($143B)
60 Significantly Impacting Margins
Percent of hospitals projected to have negative margins by 2025
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
7
CV Costs Increasingly Under the Microscope Key Market Trends Shaping the Economics of CV Care
Source Cardiovascular Roundtable research and analysis
1) Bundled Payments for Care Improvement Initiative 2) Hospital Value-Based Purchasing Hospital Inpatient Quality Reporting Merit-Based Incentive Payment System
Reimbursement Pressures bull Payment updates not keeping
pace with increasing costs
bull MACRA holding physician payments steady
bull Readmission reduction program
bull BPCI1 voluntary risk-based payment models
bull New VBP IQR MIPS2 episodic cost measures
Pay-for-Performance Programs Scrutinizing Episodic Cost
Shifting Demand to Less Profitable Services
bull Softening acute procedural volumes (eg CABG PCI)
bull Shift to outpatient medical care with lower margins
Cost-Sensitive Patients and Referring Providers bull Patients facing greater
out-of-pocket costs
bull Increasing price transparency
bull Referring providers increasingly accountable for costs under MACRA ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
8
No Relief in Sight CV Demographics Increasing Cost of Care Moving Forward
Source American Heart Association ldquoCardiovascular Disease A Costly Burden for AmericamdashProjections Through 2035rdquo (2017) Cardiovascular Roundtable research and analysis
Cost of CV Disease in United States
Drivers Impacting the Rising Cost of CV Care Delivery
Increase in staffing costs
Investment in more complex expensive technologies
Increasingly chronic comorbid patient population
2016 $555 billion
2035
$11 trillion
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
9
Carving Out a Role in Institution Efforts Clear Opportunity for CV to Support Targeted Cost Reduction Initiatives
Source Cardiovascular Roundtable research and analysis
Savings Potential
Difficulty
High Low Low
High
bull Reallocate acute care services across system
bull Rightsize excess inpatient capacity
Minimize Unwarranted Care Variation
Restructure Fixed Cost amp Assets
Reduce Labor and Supply Costs
bull Develop a foundation for implementing care standards
bull Eliminate quality shortfalls that increase cost per case
bull Update labor staffing models
bull Ensure value of supply contracting arrangements
Focus of C-Suite health system executives
More within CVrsquos realm of control
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
10
Ensuring Appropriate Use a Top CV Priority Regulatory Scrutiny Shift to Value put Appropriateness Back in the Spotlight
Source Cardiovascular Roundtable research and analysis
1) With a physician or qualified non-physician provider 2) With an independent non-interventional physician using
an evidence-based decision tool on oral anticoagulation
High-profile Legal Rulings on Misuse of CV Procedures
bull Hospitals fined millions of dollars for inappropriate PCI
bull Cardiologists found guilty of Medicare fraud for PCI and PVI
bull DOJ investigations of ICDs PVI
Value-Based Payment Initiatives
New Imaging Clinical Decision Support Requirement
bull MACRA includes use of appropriate use criteria for stress imaging as quality metrics
bull Success under bundled payments requires elimination of unnecessary care across the continuum
bull Medicare Appropriate Use Criteria Program requires ordering and performing physicians to consult AUC via electronic CDS for advance imaging exams including some for CAD
bull Reimbursement denials set to begin January 1 2021
Requirements for Shared Decision Making
bull New 2018 NCD for ICDs requires every patient receiving an ICD for primary prevention to have an encounter for shared decision-making using an evidence-based decision tool1
bull NCD for Watchman requires a formal shared decision making interaction2
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
11
19 19 18
12 11
-2 -3 -4 -5 -5
-12
-23
Outmigration of CV Services Marches On Inpatient Volumes Declining as Outpatient Takes a Greater Share
2 CV is not just increasingly an outpatient business but an ambulatory business
Source Cardiovascular Roundtable research and analysis
Get Custom Forecasts for Your Market
Access the CV Market Estimator for five year forecasts for CV services in your market
CV Five-Year Growth Projections by Sub-Service Line National All-Payer 2017-2022
Inpatient Cardiac Surgery
Outpatient Cardiac
Cath
Inpatient Arterial Disease
Inpatient Cardiac
Cath
Inpatient Medical
Cardiology
Inpatient Other
Vascular
Inpatient Cardiac
EP
Outpatient Vascular
Cath
Outpatient Cardiac
EP
Outpatient Medical
Cardiology
Outpatient Vascular Surgery
Outpatient Medical Vascular
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
12
Many Factors Driving CV ldquoOutrdquo Outpatient Shift Unlikely to Abate Given Changing Dynamics
Source Cardiovascular Roundtable research and analysis
1) Recovery audit contractor
Greater Risk for Total Cost
Shifting services contributes to lower total cost helps reduce readmissions by enhancing cross-continuum care
Market Forces Favoring Outpatient Shift of CV Services
Regulatory Scrutiny
RAC1 audits Two-Midnight Rule penalize for unnecessary inpatient admissions
Need for Hospital Efficiency
Triaging low-risk patients to lower acuity settings alleviates capacity constraints
Payer Steerage
Lower-cost settings help retain patients steered by insurers to alternate providers
Consumer Demands
Offering accessible care settings shorter wait times attracts patient and physician consumers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
13
Site-Neutral Payments Shaking Up Outpatient Strategy Already Seeing Significant Cuts to Payment Rate for Off-Campus Sites
Source Centers for Medicare and Medicaid Services CMSgov Cardiovascular Roundtable interviews and analysis
1) Medicare Physician Fee Schedule 2) Hospital Outpatient Prospective Payment System
Access our cheat sheet on site neutral payments on the online resource page
Hospital Sites Meeting Three Criteriahellip
hellipReceive Less than Half of Previous Payment in 2018 2019
Reimbursed for all services on site-specific MPFS1 rate set at 40 of HOPPS2 payment down from 50 in 2017
Hospital-owned designated as ldquooff-campus provider-based sitesrdquo
Located more than 250 yards from hospitalrsquos campus
Acquired opened or built after November 1 2015
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
14
Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD Long-Term Priorities Require Service Placement Outside of Hospital
Source ldquoImaging Program Expands to Include Level of Care Reviews FAQrdquo Anthem Blue Cross Blue Shield May 2017 Cardiovascular Roundtable research and analysis
Lower copays for patients
Payment rate differential less significant than in the past
Community practice more accessible to patients providers
More attractive to payers who are steering patients to lower-cost providers
Benefits of Shifting Select Services to Physician Practice Setting
Case in Point Anthem to Deny Some On-Campus Imaging Services bull Select Anthem insurance plans
conducting level-of-care reviews for imaging exams
bull Will deny authorizations for HOPD CT MRI exams not requiring in-hospital testing
bull Ordering provider will be given list of alternative freestanding imaging facilities
Is Echo Next For more information on Anthemrsquos payment denials read our blog
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
15
Payment Reform Accelerates with MACRA With MACRA1 Underway 2017 a Pivotal Year for Value-Based Care
3 MACRA is rewriting the rules on physician payment as well as alignment
Source CMS Cardiovascular Roundtable research and analysis
1) Medicare Access and CHIP Reauthorization Act of 2015 2) Medicare Incentive Payment System 3) Advanced Alternative Payment Model 4) Episode payment models
A Brief History of MACRA
92ndash8 2015 Senate vote in favor of MACRA
2015 Congress passes MACRA1 to overhaul flawed sustainable growth rate (SGR)
2017 First performance year tying physician payment to risk will impact 2019 payment
Access our cheat sheet on MACRA on the online resource page
What CV Providers Need to Know
Key strategies to maximize performance under MIPS
Implications of each physician payment trackmdashMIPS2 versus APM3
The future of APMs for CV following cancellation of cardiac EPMs4
How MACRA will impact physician hospital alignment
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
16
Doubling Down on Cost in Addition to Quality Tying Physician Payment to Episodic Cost Metrics
1) 2019 MACRA QPP Proposed Rule
Category Weighting Under MIPS
60 50 45
25 25 25
15 15 15 10 15
2017 2018 2019
Source CMS ldquoMedicare Program CY 2018 Updates to the Quality Payment Programrdquo November 2 2017 Cardiovascular Roundtable research and analysis
Quality Promoting Interoperability
Improvement Activities Cost
By Performance Measurement Year1 Cost Metrics 1
2
3
Total per capita cost
Medicare spend per beneficiary
Proposed eight episodic cost measures for 2019 including the following for CV
bull Elective outpatient PCI
bull Revascularization for Lower Extremity Chronic Critical Limb Ischemia
bull STEMI with PCI Ensure Patients are Attributed to a PCP bull Attribution for total per capita cost is based on
patientrsquos utilization of primary care
bull Specialists can reduce the likelihood of attribution by encouraging patients to visit their PCP
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
17
An Environment Ripe for Partnership MACRA Will Drivemdashand RequiremdashHospital-Physician Alignment
Source Medical Group Management Association 2017 Cost and Revenue Survey Cardiovascular Roundtable research and analysis
$15128 IT operating expenses per FTE physician at a physician-owned CV practice
Improve performance under MIPS
Offload reporting burden
Stabilize practice economics
Case in Point IT Expense
Think Strategically About Alignment
Hospitals employing physicians will be accountable for physician performance under MIPS
Programs may restructure physician incentive models to incorporate metrics impacting performance under MACRA
Physicians Will Increasingly Look to Employment Tohellip Health Systems Shouldhellip
Consider opportunities to scale physician network to support new or existing risk contracts
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
18
Primary Care at Center of Population Health Efforts Seeing Continued Interest in ACOs but CV Often Left On the Sidelines
4 As referring providers become more accountable for population health CV will be expected to play a bigger role
Source CMS available at datacmsgov Advisory Board ldquoWhere the ACOs arerdquo available at advisorycom Cardiovascular Roundtable interviews and analysis
220 353 404 474 525
2013 2014 2015 2016 2017
Yet CV Leaders Rarely Involved in ACO Decisions
ACO Participation Continues to Grow Total ACO Participants by Performance Year
VP Heart amp Vascular Services Large Hospital in the Midwest
Our physicians are assigned to an ACO on the contract but as far as our involvement Irsquod say minimal at bestrdquo
Director of CV Services AMC in the Northeast
Wersquove received a global view and know the goals of the ACO but we havenrsquot quite formulated our strategies to function as one in CVrdquo
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
19
Risks of Non-Action Too Great to Ignore Accountable PCPs1 Changing Referral Patterns to CV Specialists
Source Cardiovascular Roundtable research and analysis
1) Primary care providers 2) Pseudonym 3) Aortic stenosis
Potential Consequences for CV Due to Care Redesign Initiatives
ACO PCPs hesitant to refer patients for high-cost specialty services
Patients referred later in disease progression with more acute needs
CV program locked out of referral network if not demonstrating high-value care
An Extreme Example Curie Hospital2
bull Large CV program with robust structural heart program
bull Hospital-employed PCPs joined ACO started referring fewer valve patients due to fear patients would receive expensive treatments (eg TAVR)
bull Structural heart program sees volume decline threatens stability
bull Patients with AS3 referred too late in disease progression
PCPs Acting as Gatekeeper for High-End CV Care
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
20
Positioning CV to Succeed Under Care Redesign Programs Must Demonstrate Value to Secure Continued Referrals
Source Cardiovascular Roundtable research and analysis
Secure Referrer Trust Strengthen referring physician alignment by demonstrating positive outcomes and appropriate utilization
Improve Patient Access Ensure timely convenient referrals and appointments in accessible care settings
Provide Quality Care at Low Cost Deliver high-quality low-cost care to demonstrate high-value CV care delivery
Imperatives for Success Under Care Redesign Initiatives
Market to Providers Based on Value Emphasize quality of care appropriate utilization and cost reduction efforts to attract referring PCPs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
21
The Risemdashand Fallmdashof Mandatory Cardiac Bundles Future of Mandatory Programs Unclear but Voluntary Bundles Advanced
5 The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
Source CMS The Daily Briefing ldquoHHS Sec nominee signals potential shift on mandatory payment modelsrdquo January 9 2018 Cardiovascular Roundtable research and analysis
1) Episode Payment Models 2) Bundled Payments for Care Improvement
bull Mandatory bundling for CABG and AMI originally slated to go into effect July 2017
bull Final rule released on November 30th cancels both programs
Cardiac EPMs1 Cancelled
bull Mandatory bundling for hip and knee replacements originally in 67 markets
bull Final rule makes participation in 33 markets voluntary cancels planned expansion to SHFFT
CJR Scaled Back BPCI2 Advanced Introduced
bull Optional bundling program providers may opt into any of 29 inpatient and 3 outpatient conditions
bull Program scheduled to begin on October 1st 2018 and run through December 31st 2023
New HHS Secretary Signals Potential Shift on Mandatory Payment Models
ldquoIf to test a hypothesis around changing our health care system it needs to be mandatory as opposed to voluntary to get adequate data then so be itrdquo
Alex Azar Secretary of HHS January 9 2018
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
22
Bundles are Back
Source Cardiovascular Roundtable research and analysis
1) Convener participant brings together multiple downstream episode initiators coordinates participation and bears and apportions risk non-conveners only bear financial risk on their own behalf
2) Provider must have 50 of Medicare fee-for-service payments or 35 of patients through Advanced APMs to qualify in performance year 2019
Retrospective 90-day bundles including 9 inpatient and 2 outpatient CV clinical episodes
Acute care hospitals and physician group practices are eligible episode initiators either as convener or non-convener participants1
Qualifies as an Advanced Alternative Payment Model for MACRA participants may be eligible for the APM bonus if they meet paymentpatient thresholds2
Downside risk begins day 1 unlike BPCI 10 there will not be a phase-in period for risk
Applicants do not have to select episodes until August 2018 and can see target prices before joining
January 11 2018 Application portal opens
March 12 2018 Applications due must name all episode initiators
June 2018 CMS provides target prices to applicants
July 2018 CMS releases Participation Agreements
August 8 2018 Participation Agreements due to CMS must select clinical episodes
Providers Must Act Quickly
YEAR 1 BEGINS 10118 SECOND COHORT 1120
1
2
3
4
5
Five Things to Know About BPCI Advanced
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35428A
23
Episodic Scrutiny Goes Beyond BPCI Advanced CMS Tying More Payment to Risk for Episodic Cost Outcomes
Source Verma S ldquoMedicare and Medicaid Need Innovationrdquo The Wall Street Journal September 19 2017 wwwwsjcom Burwell SM ldquoProgress Towards Achieving Better Care Smarter Spending Healthier Peoplerdquo HHS January 26 2015 wwwhhsgov Cardiovascular Roundtable research and analysis
1) Inpatient Quality Reporting 2) Value-Based Purchasing Program
bull Cost category 30 of MIPS score by 2022
bull Comprises Medicare Spend per Beneficiary Total Per Capita Cost
bull 2019 proposed rule introduces eight episodic cost measures including
bullElective outpatient PCI
bullRevascularization for lower extremity chronic CLI
bullSTEMI with PCI
bull AMI HF excess days in acute care (IQR1 2018)
bull Hospital Readmissions Reduction Program (CABG AMI HF)
MACRA emphasizing episodic-cost measures
Episodic value measures added to pay-for-performance quality reporting programs eg
bull Over 500 Medicare ACOs in 2017
bull Physicians hospitals have greater interest in ACOs with significant risk in order to qualify as an Advanced Alternative Payment Model
bull Look to partner with high-value specialists
MACRA Pay-for-Performance ACOs
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
24
Private Sector Spurring More Innovation Risk-Based Payment Models Not Losing Steam for Private Payers
Source Health Care Transformation Task Force ldquoHealth Care Transformation Task Force Urges Incoming Administration and Congress to Continue Drive for Value-Based Paymentsrdquo December 6 2016 available on wwwhcttforg Cardiovascular Roundtable research and analysis
Percent of payments task force members (eg private payers) will tie to risk-based payment models by 2020
Commitment from Health Care Transformation Task Force
75
Medicare Advantage Continues to Grow
CMS testing Medicare Advantage Value-Based Insurance Design Model for enrollees in select states
Medicare Advantage will count as a MACRA APM starting in performance year 2019
Percentage of Medicare population enrolled in MA plans in 2025 40
Private payers piloting Centers of Excellence models designations to steer patients to high-value specialty providers
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
25
The Perils of Teaching to the Test Reactive Strategies Not Pathways to Success in an Uncertain Market
Source Cardiovascular Roundtable research and analysis
2010 2016
30-day HF Readmission Penalties Announced
Response
Mandatory cardiac bundles cancelled
No-Regrets Priorities
Build an infrastructure to eliminate unwarranted care variation implement evidence-based care standards
Partner across the continuum to improve outcomes and costs
Prioritize investments based on the demands of your market
Lower the cost of care delivery with appropriate staffing utilization
Old Response to Risk New Plan for Risk
bull Focus on HF
bull Hire HF nurse navigators
bull Focus on 30-days post-discharge
Mandatory Cardiac Bundles Announced
Response
bull Redesign physician incentives to support CABG AMI outcomes
bull Support PAC providers in delivering high-quality care through 90 days
First mandatory cardiac bundles track CABG AMI outcomes for 90-days
Planning for an Uncertain Future
Market Shift Market Shift
2018+
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-
copy2018 Advisory Board bull All Rights Reserved bull advisorycom bull 35425A
26
5 Market Realities Impacting CV Providers
Source Cardiovascular Roundtable research and analysis
1
2
3
4
5
Margin pressure will only intensify for CV
CV is not just increasingly an outpatient business but an ambulatory business
MACRA is rewriting the rules on physician payment as well as alignment
As referring providers become more accountable for population health CV will be expected to play a bigger role
The shift to risk is not abatingmdashmore CV payment will be tied to cross-continuum cost and quality in the future
- Cardiovascular Market Update 2018
- Slide Number 2
- What a Year and a Half itrsquos Been
- Raising Questions About the Future of Riskhellip
- 5 Market Realities Impacting CV Providers
- Guess Whatrsquos Not Getting Repealed
- CV Costs Increasingly Under the Microscope
- No Relief in Sight
- Carving Out a Role in Institution Efforts
- Ensuring Appropriate Use a Top CV Priority
- Outmigration of CV Services Marches On
- Many Factors Driving CV ldquoOutrdquo
- Site-Neutral Payments Shaking Up Outpatient Strategy
- Tomorrowrsquos Ambulatory Strategy Looks Beyond HOPD
- Payment Reform Accelerates with MACRA
- Doubling Down on Cost in Addition to Quality
- An Environment Ripe for Partnership
- Primary Care at Center of Population Health Efforts
- Risks of Non-Action Too Great to Ignore
- Positioning CV to Succeed Under Care Redesign
- The Risemdashand Fallmdashof Mandatory Cardiac Bundles
- Bundles are Back
- Episodic Scrutiny Goes Beyond BPCI Advanced
- Private Sector Spurring More Innovation
- The Perils of Teaching to the Test
- 5 Market Realities Impacting CV Providers
-