PowerPoint Presentation

Mary Carr, RN MPH, V.P. for Regulatory Affairs, National Association of Home Care & Hospice Home health Regulatory Roundup ---- Part 2FOCUSValue-Based Purchasing Pilot program

IMPACT Act

Joint Replacement Bundling

Value Based Purchase PilotHHS Goal 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, 50 percent of payments to these models by the end of 2018. 85 percent of all FFS Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Value Based Purchasing and the Hospital Readmissions Reduction ProgramsValue-Based Purchasing PilotEarlier comments to CMSConcern on the magnitude of the adjustmentEncouragement of pay for performance and pay for reportingMeasures: exclude 5-Star system, HHCAPS re-hospitalizations, OASIS measuresSupport risk adjustment strategy, voluntary participationValue-Based Purchasing PilotProposed states: MA, MD, NC, FL, WA, AZ, IA, NE, TN9 regionsRandomized selection w/in each regionSubject to changeFactors considered in setting up regionsHHA sizeUtilization levelsRural Dual-eligiblesProportion of minorities Value-Based Purchasing Pilotsmaller-volumeexempt from HHCAPSlarger-volumeHHCAPS participantValue-Based Purchasing PilotPayment Adjustment Timeline5 performance years beginning in 20162016 > 2018 payment adjustment (5%)2017 > 2019 payment adjustment (5%)2018 > 2020 payment adjustment (6%)2019 > 2021 payment adjustment (8%)2020 > 2022 payment adjustment (8%)

May modify schedule beginning in 2019 with more frequent adjustmentsValue-Based Purchasing PilotMeasures10 Process; 15 Outcome; 4 New MeasuresOASIS; Claims; HHCAPSPrinciples:Broad set to capture HHA complexitiesFlexibility to include IMPACT Act proposed PAC measuresDevelop second-generation measures of outcomes, health and functional status, shared decisionmaking and patient activationBalance of process, outcome, and patient experienceAdvance ability to measure cost and valueMeasures on appropriateness and overusePromote infrastructure investmentsValue-Based Purchasing Pilot: MeasuresOutcomeImprovement in ambulation-locomotion (OASIS)Improvement in bed transferringImprovement in BathingImprovement in DyspneaDischarged to communityImprovement in pain interfering with activityImprovement in oral medication managementPrior functioning ADL/IADLAcute care hospitalization (unplanned w/in 60 days; during first 30 days) (Claims)Emergency Department use w/o hospitalizationCare of Patients (CAHPS)Communication between providers and patients (CAHPS)Specific care Issues (CAHPS)Overall rating (CAHPS)Willingness to recommend the agency (CAHPS)Value-Based Purchasing Pilot: MeasuresProcessDepression assessment conducted (OASIS)Influenza vaccine data collection Influenza immunization received Pneumococcal vaccine received Reason Pneumococcal vaccine not receivedDrug educationTimely initiation of careCare management: Types and sources of assistance Pressure ulcer prevention and care Multifactor fall risk assessment /pts who can ambulate

Value-Based Purchasing Pilot: MeasuresNew Measures: HHA reporting through portal

Influenza vaccination of HH staff Herpes zoster )shingles) vaccines for HHA patientsAdvanced Care planningAdverse event for improper medication

Value-Based Purchasing Pilot: ScoringQuarterly assessmentTotal Performance Score (TPS): higher of achievement or performance score in each measureAll Outcome and Process measures have equal weight and account for 90% of TPSNew Measure reported accounts for 10% and each has equal weightPoints only for applicable measures (20 episodes per year)0 to 10 points on each Outcome and Process measure10 or 0 points on New Measures (report vs. no report)Value-Based Purchasing Pilot: ScoringAchievement threshold: median of all HHA performance in baseline periodbenchmark: mean of top decile of all HHA performance in baseline period State specific; separate smaller and larger HHAsEach measure is separately scoredValue-Based Purchasing Pilot: ScoringAchievement scoringHHA with performance equal to or higher than benchmark receives 10 pointsHHA with performance equal to or greater than achievement threshold receives 1-9 points based on formula: 9 X (HHA performance score-achievement threshold) divided by (benchmark-achievement threshold) + 0.5HHA with performance less than achievement threshold receives 0 points

Value-Based Purchasing Pilot: ScoringImprovement scoringHHA with performance equal to or higher than benchmark receives 10 pointsHHA with performance greater than its baseline period receives 1-9 points based on formula: 10 X (HHA performance period score-HHA baseline period score) divided by (benchmark-HHA baseline period score) - 0.5HHA with performance equal or less than baseline period score receives 0 points

Value-Based Purchasing Pilot: ScoringTotal Performance Score (TPS)Use only those measures out of the 25 with 20 or more episodesUse higher of improvement or achievement scoreDivide total earned points by total possible points multiplied by 90Add New Measure points (points earned/possible points X 10)

Value-Based Purchasing Pilot: PreviewOpportunity to review quarterly quality reports10 days to request recalculationJuly 2016 first reportOpportunity to review TPS and payment adjustment calculationsAugust 1, 2017 first notification10 days to request recalculationFinal report no later than November 1, 2017VALUE BASED PURCHASING PILOT: IMPACT 10% of HHAs would experience a -5% or greater reduction under the 8% withhold level (2021-2022)

NAHC ADVOCACY PLANContest Value-Based Purchasing Pilot design5-8% at risk is unsustainableLost resources prevent performance improvementUse of public comment process by all stakeholdersSecure beneficiary advocate supportCongressional intervention

HHQRP - IMPACT ACT Passed Sept 2014 Requires PAC provider report standardized assessment data and quality, resource, and other measures HHAs, SNFs, IRFs, and LTCHsTime line Quality measure on domains between 2016-2019Assessment data HHA 2019; others 2018

IMPACT ACTDomains (HH)Functional and cognitive status and changes in functional and cognitive status (2019)Skin integrity and changes (2017)Medication reconciliation (2017)Incident of falls (2019)Transition of care (2019)Resource use measures, including total estimated Medicare spending per beneficiary(2017)Discharge to community (2017)Measures to reflect all-condition risk- adjusted potentially preventable hospital readmission rates (2017)

IMPACT ACTStandardized Data Assessment Data Categories Functional statusCognitive function and mental statusSpecial services, treatments, and interventionsMedical conditions and co-morbiditiesImpairmentsOther categories required by the SecretaryHH 2019 Quality Measures (IMPACT)Functional status, cognitive function, and changes in function and cognitive functionPercent of patients/residents with an admission and discharge functional assessment and a care plan that addresses functionSkin integrity and changes in skin integrityPercent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678 )Incidence of major fallsPercent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

IMPACT ACT 2016 HH Proposed rule included:

Skin integrity and changes in skin integrityPercent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678 )

Uses OASIS C-1 data set items M01308 and M01309

Feedback on this measure and future measures to implement the IMPACT Act CMS measures under consideration (MUC) list Measure Application Partnership(MAP)-National Quality Forum (NQF)Guides HHS in measure selection for Federal programs Public - private partnership IMPACT ACT CMS Measure Management web page Call for Measures Public comments on measures Technical Expert Panel nominations

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/index.html

IMPACT ACT IMPACT ACT NQF Calendar of activities: http://www.qualityforum.org/EventList.aspxMAP Coordinating committee project page: http://www.qualityforum.org/Project_Pages/MAP_Coordinating_Committee.aspxMAP PAC-LTC workgroup project page: http://www.qualityforum.org/Project_Pages/MAP_Post-Acute_CareLong-Term_Care_Workgroup.aspxCMSs Pre-Rulemaking page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rule-Making.html

IMPACT Act Open Door Forums (ODFs): SNF, LTC: October 29 and December 1HH, Hospice, DME: November 4 and December 16

Special Open Door Forum (SODF): Understanding The IMPACT Act-Patient and Family Focused for Informed Decision Making. Wednesday, October 28, 2015, from 1:00 p.m. 3:00p.m. Eastern Time

CMS Quality Conference Presentation: December 1 3, 2015 (planned)

CMS National Training Program Partner Update Webinar: January 2016 (planned)

CMS Proposed Joint Replacement BundlingCMS proposes to bundle payment for joint replacement services under 1115A waiver

MS-DRG 469 (Major joint replacement or reattachment of lower extremity with Major Complications or Comorbidities (MCC)) or MS-DRG 470 (Major joint replacement or reattachment of lower extremity without MCC).75 geographic areasMandatory participation with some exclusionsIncludes hospitalization plus all Part A and Part B related services for 90 days post-dischargeBegins January 1, 2016; 5 performance years

https://www.federalregister.gov/public-inspection/2015/07/13 CMS Proposed Joint Replacement BundlingHospital as the risk bearing participant

Encourages, but does not dictate care and financial integration

Retains patient freedom of choice of providersNo direct care control

Reconciliation process on shared savings payment or overpayment recoveryPhase-in with no recovery until year 2

Certain rule waivers3-day hospitalization pre-SNFPost-discharge home visits where no home health coverageTelehealth site of service (permits service in home)Rejects a homebound waiver