maryland’s medicare waiver what is it? how do we fit? gayle olano hurt april 21, 2015 cmsa of the...
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Maryland’s Medicare Waiver
What is it? How do we fit?
Gayle Olano HurtApril 21, 2015
CMSA of the Chesapeake Annual Conference
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Objectives• Understand the frame work for Maryland's
Medicare waiver.• Identify the key pay for performance components
of the waiver proposal• Visualize how case management can play a role
in successful achievement of the wavier proposals goals
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Setting the Stage• Medicare Waiver (1977)• Exempt from Inpatient and Outpatient
Prospective Payment Systems (IPPS & OPPS)• Meet specific criteria (e.g., cost containment)
o Payment per admission• Flexibility to set our own model & rates
o All payer modelo Health Services Cost Review Commission
(HSCRC)• Maryland - only state remaining
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Challenges• Challenges in this new Era of payment reform• Meeting the waiver test
o Rising hospital costs• Value
o Cost containment o What about quality of care?
• Integration and care coordinationo $ Incentive on admissions not integration
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CMS P4R and P4P
HHCAHPSHHQR
IQR,OQR, IPFQRVBP/HCAHPS (P4P)Readmissions (P4P)HACs (P4P)Meaningful Use
ACUTE CARE HOSPITALS (7%+)
MEDICAL GROUPS (6+%)Meaningful Use
PQRS / CGCAHPSPhysician VM (P4P)
HOME HEALTH (2%)
OQR
HOSPITAL OUTPATIENT (2%)
ICHCAHPSESRD-QIP (P4P)
DIALYSIS CENTERS (2%)
Hospice CAHPSHQR
HOSPICE (2%)
LTCHQR
NHCAHPSSNFQR (2019)
SKILLED NURSING (2%)
IRFQR
LONG-TERM CARE (2%)
REHAB HOSPITALS (2%)
IPFQRINPATIENT PSYCHIATRIC FACILITY
(2%)Performance EvaluationQBRARR (& PAU)PPCs
Performance Evaluation
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Beyond CMS
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Reimbursement Model?
• Value and the reimbursement model• Value based payments• FFS Integrated
o Accountable Care Organizationso Patient Centered Medical Homeso Bundled paymentso Shared savings
• Fit within context of Maryland Medicare Waiver?
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Value
COST
QUALITY + OUTCOMES
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New Waiver• 5 year demonstration
Federal Triple Aim• Better Care• Healthy People/Communities• Affordable Care
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Framework
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Key Components• Quality Based Revenue (2017)
• Healthcare Acquired Conditions (MHAC/PPC)
25%
5%
45%
25%
Fed
45%
5%
50%
MdClinical ProcessHCAHPSOutcomesEfficiency
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Key Components• Quality Based Revenue (2017)
• Healthcare Acquired Conditions (MHAC/PPC)
25%
5%
45%
25%
Fed
45%
5%
50%
MdClinical ProcessHCAHPSOutcomesEfficiency
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Key Components• Admission-Readmission Reduction (ARR)
o 30 day all cause < national by end of 2018o One example calculation
• New Concept: Potentially Avoidable Utilizationo 30 day all causeo Revisits include inpatient, *observation, & *ER
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Case Management• What are the goals and purposes?• Improve quality • Control costs• Coordination & Care Access
• Case Management functions*• Assess• Enable • Facilitate• Evaluate /Monitor
*(Abbreviated from Moore 1990 model)
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Case Management• Case Management functions• Assess• Enable • Facilitate• Evaluate /Monitor
(Abbreviated from Moore 1990 model)
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Case Management• Impact on payment based reimbursement?• Outcomes measures• Efficiency measures• Readmission reduction • Potentially avoidable utilization
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Discussion / Q&A