CMMI HCIA Awardee Progress Report: Ochsner Clinic Foundation ...

CMMI HCIA Awardee Progress Report: Ochsner Clinic Foundation ...

The Search for Health Equity through Legislation and Regulation R e n a r d M u r r ay, D . M . Consortium Administrator for Quality I m p r o v e m e n t a n d S u r v e y a n d C e r t i fi c a t i o n s Operations (CQISCO) Centers for Medicare & Medicaid Services (CMS) October 14, 2016 Disclaimers 2 This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official

Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. 3 Presentation Objectives CMS Overview CMS Efforts in Delivery System Reform CMS Quality Programs and Initiatives Quality Measurement to Drive Improvement- Quality Payment Program (MACRA/MIPS Proposed Rule, April 27, 2016) Center for Medicare and Medicaid Innovation (CMMI) Consortium of Quality and Survey and Certification efforts to support delivery reform (CQISCO)

4 Centers for Medicare & Medicaid Services (CMS) 5 CMS Office of Minority Health Mission Eliminate disparities in health care quality and access Ensure the needs of minority populations are represented in CMS policies/programs Vision All CMS beneficiaries have achieved their highest level of health, and disparities in health care quality and access have been eliminated

6 Measuring and Reporting Disparities CMS released Medicare Advantage plan data stratified by race and ethnicity, including: Patient Experience Medicare Consumer Assessment of Healthcare Providers and Systems (Medicare CAHPS) Survey (2013-2014) Clinical Quality Healthcare Effectiveness Data and Information Set (HEDIS): from Medicare health plans nationwide (Measurement years 2013-2014) 7 Disparities: Clinical Measures

Clinical Measures with Few or No Racial/Ethnic Differences All racial/ethnic groups were more likely than White Medicare beneficiaries to have at least one follow-up visit about a higher-risk medication. There are no disparities in the appropriate monitoring of patients taking long-term medications. 8 CMS Health Equity Framework Size and Scope of CMS Responsibilities 9

CMS is the largest purchaser of health care in the world (FY 2016 Budget estimate of $970.8 billion) Combined, Medicare and Medicaid pay approximately onethird of national health expenditures. (approximately 23% of federal budget) CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP (Childrens Health Insurance Program); or roughly 1 in every 3 Americans. The Medicare program alone pays out over $1.5 billion in benefit payments per day. CMS answers about 75 million inquiries annually. An estimated 20 million people gained health insurance coverage between the passage of the Affordable Care Act in 2010. 10 Healthier. Better. Smarter. So we will continue to work across sectors

and across the aisle for the goals we share: better care, smarter spending, and healthier people. 11 CMS Measures of Success Better care and lower costs: Beneficiaries receive high quality, coordinated, effective, efficient care. As a result, health care costs are reduced. Improved prevention and population health: All Americans are healthier and their care is less costly because of improved health status resulting from use of preventive benefits and necessary health services. Expanded health care coverage: All Americans have access to affordable health insurance options that protect them from financial hardship and ensure quality health care coverage. 12 CMS Efforts in Delivery System

Reform CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people Evolving future state Historical state Public and Private sectors Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care Systems and Policies

Fee-For-Service Payment Systems Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments

Medical Homes Quality/cost transparency 13 14 What is Value-Based Purchasing? Transforms CMS from a passive payer (fee-forservice only) to an active purchaser of higher quality, more efficient health care Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program Initiatives: pay for reporting, pay for performance, gain sharing, competitive bidding, bundled payment, coverage decisions, direct provider support (i.e. EHR incentive etc) 15 In January 2015, HHS announced goals for valuebased payments within the Medicare FFS system 16 CMS is aligning with private sector and states to drive delivery system reform

CMS Strategies for Aligning with Private Sector and states Convening Stakeholders Incentivizing Providers Partnering with States 17 CMS Quality Programs and Initiatives To support Quality Strategy goals and objections, CMS: Provides financial incentives that reward providers for adopting best practices that decrease harm (e.g., Value-Based Purchasing, Medicare Advantage Quality Bonus payments, and the End Stage Renal Disease Quality Incentive Program). Established Quality Improvement Organization initiatives, such as the Everyone with Diabetes Counts program, which gives each person with diabetes and their family an active role in care.

Is a lead partner in the Million Hearts initiative, which seeks to reduce the incidence of heart attacks and strokes by 1 million by 2017. Established the Hospital Value-Based Purchasing Program, which adjusts hospital payments made by Medicare for inpatient services based on their performance on measures that fall into a number of domains, including patient safety, clinical outcomes, and patient experience. 18 Mission of QIOs & Key Attributes Mission Improve Quality Improve Effectiveness and Efficiency Protect Beneficiary Rights Key Attributes Maintain local presence Alignment with HHS National Quality Strategy and CMS Quality Strategy Exhibits and promotes flexibility 19



CO Qsource Health Services Advisory Group Stratis Telligen TMF Great Plains Quality Innovation Mountain Pacific Quality Health Fdn HealthInsight Qualis Contracts pending award as of 7/18/14: Indiana, Puerto Rico, Virgin Islands NJ MO CA DC TN OK


KS HealthCentric Advisors IPRO Quality Insights VHQC Georgia Medical Care Foundation PR RI OH UT GA LA Regio n QIO

1 LIVANTA 2 KEPRO 3 KEPRO 4 KEPRO 5 LIVANTA FL 20 The QIO Programs Approach to

Clinical Quality 21 End Stage Renal Disease (ESRD) Networks 18 Networks cover 50 states, 5 territories and D.C. Small staff, clinical backgrounds Contracted by CMS to Conduct quality improvement projects Collect data related to the ESRD program Investigate complaints/grievances 22 MACRA: What is it? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is: Bipartisan legislation repealing the Sustainable Growth Rate (SGR) Formula

Changes how Medicare rewards clinicians for value over volume Created Merit-Based Incentive Payments System (MIPS) that streamlines three previously separate payment programs: Physician Quality Reporting Program (PQRS) Value-Based Payment Modifier Medicare EHR Incentive Program Provides bonus payments for participation in eligible alternative payment models (APMs) 23 How MACRA gets us closer to meeting HHS payment reform goals The Merit-based Incentive Payment System helps to link fee-for-service payments to quality and value.

The law also provides incentives for participation in Alternative Payment Models via the bonus payment for Qualifying APM Participants (QPs) and favorable scoring in MIPS for APM participants who are not QPs. New HHS Goals: 2016 2018 30% 50% 85% 90% All Medicare fee-for-service (FFS) payments (Categories 1-4) Medicare FFS payments linked to quality and value (Categories 2-4)

Medicare payments linked to quality and value via APMs (Categories 3-4) Medicare payments to QPs in eligible APMs under MACRA 24 Quality Payment Program Repeals the Sustainable Growth Rate (SGR) Formula Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS) Provides incentive payments for participation Advanced Alternative Thein MeritAdvanced Payment Models based (APMs) Alternative Payment Models (APMs)

Incentive Payment System (MIPS) First step to a fresh start Were listening and help is available A better, smarter Medicare for healthier people Pay for what works to create a Medicare that is enduring Health information needs to be open, flexible, and usercentric or 25

How will physicians and practitioners be scored under MIPS? A single MIPS composite performance score will factor in performance in 4 weighted performance categories: a Qualit y Resource use Clinical practice improveme nt activities : Advancin g care informati on

26 Alternative Payment Models (APMs) APMs are new approaches to paying for medical care through Medicare that incentivize quality and value. Accordin g to MACRA law, APMs include: MSSP (Medicare Shared Savings Program) Demonstration under the Health Care Quality Demonstration Program

Demonstration required by Federal Law CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award) MACRA does not change how any particular APM rewards value. APM participants who are not QPs will receive favorable scoring under MIPS. Only some of these APMs will be eligible APMs. 27 Health Care Payment Learning and Action Network is actively engaging the healthcare community 75+ organizations have committed support, including AARP, Anthem, Humana, National Partnership for Women & Families,

Partners Healthcare, Rite Aid, Walgreens, Walmart, States of MA and NY, and many others including 8 of the 10 largest payers based on national market share. +{ 6,000 { Work Groups have formed with multiple work products underway: registered participants Accountable Care Organizations: Participation in Medicare ACOs 28 growing rapidly 477 ACOs have been established in the MSSP, Pioneer ACO,

Next Generation ACO and Comprehensive ESRD Care Model programs* This includes 121 new ACOS in 2016 (of which 64 are risk- bearing) covering 8.9 million assigned beneficiaries across 49 ACO-Assigned Beneficiaries by County** states & Washington, DC * January 2016 ** Last updated April 2015 29 Center for Medicare and Medicaid Innovation (CMMI) 30 The CMS Innovation Center Identify, Test, Evaluate, Scale The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditureswhile preserving or

enhancing the quality of care furnished to individuals under such titles. - The Affordable Care Act The CMS Innovation Center The The purpose purpose of of the the [Center] [Center] is is to to test test innovative innovative payment payment and and service service delivery delivery models models to to reduce reduce program

program expenditureswhile expenditureswhile preserving preserving or or enhancing enhancing the the quality quality of of care care furnished furnished to to individuals individuals under under such such titles titles Three Three scenarios scenarios for for success success 1. 1. Quality

Quality improves; improves; cost cost neutral neutral 2. 2. Quality Quality neutral; neutral; cost cost reduced reduced 3. 3. Quality Quality improves; improves; cost cost reduced reduced (best (best case) case) If If a a model model meets meets one one of

of these these three three criteria criteria and and other other statutory statutory prerequisites, prerequisites, the the statute statute allows allows the the Secretary Secretary to to expand expand the the duration duration and and scope scope of of a a model

model Section 3021 of Affordable Care Act 31 32 CMS has engaged the health care delivery system and invested in innovation across the country Sites where innovation models are being tested Source: CMS Innovation Center website, July 2016 Models run at the state level 33 CMS Innovations Portfolio Accountable Care Pioneer ACO Model Medicare Shared Savings Program (housed in Center for Medicare)

Advance Payment ACO Model Comprehensive ERSD Care Initiative Next Generation ACO Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Home Health Value Based Purchasing Medicare Care Choices Learning and Diffusion Bundled payment models Partnership for Patients Transforming Clinical Practice Community-Based Care Transitions Health Care Innovation Awards Accountable Health Communities State Innovation Models Initiative SIM Round 1 SIM Round 2 Maryland All-Payer Model

Bundled Payment for Care Improvement Models 1-4 Oncology Care Model Comprehensive Care for Joint Replacement Initiatives Focused on the Medicaid Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program Dual Eligible (Medicare-Medicaid Enrollees) Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents Medicare Advantage (Part C) and Part Million D Hearts Cardiovascular Risk Reduction Medicare Advantage Value-Based Insurance Design Model Health Care Payment Learning and Action

Network Information to providers in CMMI models Shared decision-making required by many models 34 35 Survey & Certification Conduct Surveys for the purpose of certifying to the Secretary compliance & non-compliance of providers & suppliers of services & re-surveying such entities at such time as the Secretary may direct We inspect health care providers for compliance with the Medicare health & safety standards Liaison to state agencies for determination of eligibility Approve, deny, or terminate certification Interpret guidelines, policies & procedures Levy enforcement actions Conduct Surveys for the purpose of certifying to the Secretary compliance & non-compliance of providers & suppliers of services & re-surveying such entities at such time as the Secretary may direct 36

Types of Surveys Initial Recertification Revisit Complaint Validation Federal monitoring ComparativeRO surveyors replicate a SA survey (look-behind) Federal Oversight Support Survey (FOSS) RO observes & evaluates a SA survey teams conduct of the actual survey 37 and toward transforming our health care system. The Social Security Number Removal Initiative (SSNRI) Center for Program Integrity (CPI) www.presidential Thank You

Renard Murray r [email protected] ov 404-562-7150

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