Accelerating Care and Payment Innovation: The CMS Innovation Center

College of American Pathologists

Sean Cavanaugh Deputy Director Center for Medicare and Medicaid Innovation May 6, 2013

“ The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.

- The Affordable Care Act

The CMS Innovation Center

Identify, Test, Evaluate, Scale

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Rapid-Cycle Evaluation

• “Be part of the solution”: Gather information and leverage our claims data to promote and support continuous quality improvement in the marketplace.

• Speed: Improve our data systems and our ability to use data so that we can frequently and rapidly assess effectiveness and provide feedback to providers.

• Rigor: Use advanced epidemiologic methods to measure effectiveness to meet a high standard of evidence and allow for certification.

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Learning and Diffusion

Integral part of every model team

(1) Applying rigorous methods for rapidly studying and improving performance.

(2) Applying innovative approaches to harvest, refine and spread what works

(3) Bringing people together to learn from one another to accelerate the pace of change

Activities tailored for each initiative

o ACO Accelerated Development Learning Sessions

o Learning Infrastructure for Partnership for Patients 4

CMS Innovations Portfolio

Accountable Care Organizations (ACOs) • Medicare Shared Savings Program (Center for

Medicare) • Pioneer ACO Model • Advance Payment ACO Model • PGP Transition Demonstration • Comprehensive ERSD Care Initiative

Primary Care Transformation • Comprehensive Primary Care Initiative (CPC) • Multi-Payer Advanced Primary Care Practice

(MAPCP) Demonstration • Federally Qualified Health Center (FQHC) Advanced

Primary Care Practice Demonstration • Independence at Home Demonstration • Graduate Nurse Education Demonstration

Bundled Payment for Care Improvement • Model 1: Retrospective Acute Care • Model 2: Retrospective Acute Care Episode & Post Acute • Model 3: Retrospective Post Acute Care • Model 4: Prospective Acute Care

Capacity to Spread Innovation • Partnership for Patients • Community-Based Care Transitions • Million Hearts • Innovation Advisors Program

Health Care Innovation Awards

State Innovation Models Initiative

Initiatives Focused on the Medicaid Population • Medicaid Emergency Psychiatric Demonstration • Medicaid Incentives for Prevention of Chronic

Diseases • Strong Start Initiative

Medicare-Medicaid Enrollees • Financial Alignment Initiative • Initiative to Reduce Avoidable Hospitalizations of

Nursing Facility Residents

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Accountable Care

• Medicare Shared Savings Program (Center for Medicare)

• Pioneer ACO Model

• Advance Payment Model

• Accelerated Development and Learning Sessions

• Comprehensive ESRD Care Initiative

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Geographic Distribution of ACO Assignees (Over 4 million total assignees in all programs)

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The Pioneer ACO Model

• Designed for health care organizations and providers that are already experienced in coordinating care

• Requires ACOs to create similar arrangements with other payers.

• Option for transition from shared savings to population-based payment in Year 3

• 32 Participating ACOs announced in December 2011

• Over 700,000 aligned beneficiaries

• First performance period began in January 2012.

GOAL: Test payment arrangements with higher risk and reward than MSSP, including partial- and full capitation arrangements, as well as a transition from FFS to population based payments.

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Advance Payment ACO Model

• Open only to ACOs participating in the Medicare Shared Savings Program.

• Participants receive three payments: – Upfront variable payment – Monthly variable payment – Fixed monthly payment

• Payments are returned through future shared savings

• Three start dates: – April 1 start date: 5 ACOs selected – July 1 start date: 15 ACOs selected – January 1 start date: 15 ACOs selected

GOAL: Test whether advance payments enhance the ability of ACOs to effectively coordinate care and generate Medicare savings.

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Comprehensive ESRD Care Initiative

• Partnering with groups of health care providers and suppliers - ESRD Seamless Care Organizations (ESCOs) – Must include dialysis provider and nephrologist

• ESCOs must have minimum of 500 “matched” beneficiaries – Beneficiaries with ESRD “matched” to ESCO based on where they receive

dialysis – Fee for service Medicare beneficiaries with ESRD

• ESCOs evaluated on performance on quality measures

• ESCOs successful in lowering total Part A and B costs can share in savings

• Letters of Intent due March 15

• Applications due May 1

GOAL: Test new model of payment and care delivery specific to Medicare beneficiaries with ESRD.

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Primary Care

• Comprehensive Primary Care (CPC) Initiative • Multi-Payer Advanced Primary Care Practice

(MAPCP) Demonstration • Federally Qualified Health Center (FQHC)

Advanced Primary Care Practice Demonstration • Independence at Home • Graduate Nursing Demonstration • Medicaid Health Home State Plan Option

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• Collaborating with public and private insurers in purchasing high value primary care in communities they serve. – Requires investment across multiple payers

– individual health plans, covering only their members, cannot provide enough resources to transform primary care delivery.

• Medicare will pay approximately $20 per beneficiary per month (PBPM) then move towards smaller PBPM to be combined with shared savings opportunity.

• The 7 markets selected: Ohio (Dayton), Oklahoma (Tulsa), Arkansas, Colorado, New Jersey, Oregon, New York (Hudson Valley)

CPC Initiative

GOAL: Test a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care.

Comprehensive Primary Care Initiative

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Multi-payer Advanced Primary Care Practice Model

• Medicare will participate in existing State multi-payer health reform initiatives.

• Must include participation from Medicaid and private health plans.

• Monthly care management fee for beneficiaries receiving primary care from Advanced Primary Care practices.

• Eight states selected: Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan and Minnesota.

GOAL: Test the effectiveness of offering providers a common payment method from Medicare, Medicaid, and private health plans.

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Federally Qualified Health Center (FQHC) Advanced Primary Care Demonstration

• Open to FQHCs that have provided medical services to at least 200 Medicare beneficiaries in previous 12-month period.

• FQHC receives care management fee for each Medicare beneficiary enrolled.

• 500 FQHCs selected. • Performance year started Nov 1st 2011.

GOAL: Evaluate impact of the advanced primary care practice model in the Federally Qualified Health Center (FQHC) setting.

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Bundled Payments for Care Improvement

Four models:

1. Acute care hospital stay only

2. Acute care hospital stay plus post-acute care

3. Post-acute care only

4. Prospective payment of all services during inpatient stay

GOAL: Test payment models that link payments for multiple services patients receive during an episode of care for effectiveness in promoting coordination across services and reducing the cost of care.

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Model 1 Model 2 Model 3 Model 4

Episode All acute patients, all

DRGs Selected DRGs +

post-acute period Post acute only for

selected DRGs Selected DRGs

Services included in the bundle

All part A DRG-based payments

Part A and B services during the initial

inpatient stay , post-acute period and

readmissions

Part A and B services during the post-acute

period and readmissions

All Part A and B services (hospital,

physician) and readmissions

Payment Retrospective Retrospective Retrospective Prospective

Participants 3 representing 22

health care facilities

55 representing 193 health care

organizations

14 representing 164 health care

organizations

37 representing 76 health care

facilities

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Bundled Payments: 4 Models

Bundled Payments for Care Improvement

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Financial Alignment Initiative

Two Demonstration Models:

• Capitated Model: Three-way contract among State, CMS and health plan to provide comprehensive, coordinated care in a more cost-effective way.

• Managed FFS Model: Agreement between State and CMS under which States would be eligible to benefit from savings resulting from initiatives to reduce costs in both Medicaid and Medicare.

Participating states: Massachusetts, Washington, Ohio

GOAL: Test two models for effectiveness in improving quality of care for Medicare-Medicaid enrollees and reducing costs to Medicare and Medicaid.

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Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

• Participants implement evidence-based interventions at a minimum of 15 Medicare-Medicaid certified nursing facilities.

• 7 organizations selected to participate

• Interventions must:

• Improve beneficiary safety through coordinating management of prescription drugs

• Bring onsite staff to collaborate and coordinate with providers

• Demonstrate a strong evidence base

GOAL: Test evidence-based interventions for their effectiveness in reducing preventable inpatient hospitalizations among residents of nursing facilities.

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Capacity to Spread Innovation

• Partnership for Patients

• Community Based Care Transition Program

• Million Hearts

• Innovation Advisors Program

• Care Innovations Summit

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Partnership for Patients

40% G O A L S :

20%

Reduction in Preventable Hospital- Acquired Conditions 1.8 Million Fewer Injuries | 60,000 Lives Saved

Reduction in 30-Day Readmissions 1.6 Million Patients Recover without Readmission

partnershipforpatients.cms.gov

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Hospital Engagement Networks

• American Hospital Association • Premier • VHA • NC Hospital Assoc • Intermountain HealthCare • GA Hospital Assoc • TX Hospital Assoc • MN Hospital Assoc • NY State Hosp Assoc • IA Healthcare Collaborative • PA Hospital Assoc • WA Hospital Assoc • Dallas Fort Worth Regional Hospital

Assoc

• OH Hospital Assoc • NJ Hospital Assoc • Ascension Health • TN Hospital Assoc • MI Hospital Assoc • National Public Hospital & Health

Institute • Lifepoint • Joint Commission Resources • OH Children’s Hospital • Dignity Healthcare • NV Hospital Assoc • Carolinas Health Care • University Health Care Collaborative

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Community-based Care Transitions Program (CCTP)

GOALS: Test models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries

• Open to community-based organizations partnered with hospitals

• Currently 82 participants

• $500 million total funding

• Participants in all 10 CMS Regions

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Million Hearts Initiative

Focus, coordinate, and enhance cardiovascular disease prevention activities across the public and private sectors.

• Will scale-up proven clinical and community strategies to prevent heart disease and stroke across the nation.

• Led by Centers for Disease Control and Prevention and Centers for Medicare and Medicaid Services within HHS.

• Partners include: American Heart Association, YMCA, and many other private and public organizations.

GOAL: Prevent 1 million heart attacks and strokes in 5 years

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Initiatives Focused on the Medicaid Population

• Medicaid Emergency Psychiatric Demonstration

• Medicaid Incentives for Prevention of Chronic Diseases

• Strong Start Initiative

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Medicaid Emergency Psychiatric Demonstration

• Demonstration provides up to $75 million in federal matching funds over 3 years

• Demonstration pays for inpatient services necessary to stabilize the psychiatric emergency

• 11 States – Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia – and the District of Columbia applied and were selected to participate

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GOAL: Test whether Medicaid Beneficiaries aged 21 to 64 who are experiencing a psychiatric emergency (suicidal or homicidal thoughts or gestures) get more immediate, appropriate care when institutions for mental diseases (IMDs) receive Medicaid reimbursement

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Medicaid Incentives for Prevention of Chronic Diseases (MIPCD)

One or more of the following prevention goals must be addressed: • tobacco cessation • controlling or reducing weight • lowering cholesterol • lowering blood pressure • avoiding the onset of diabetes or in the case of a diabetic, improving

the management of the condition

Grants awarded to: California, Montana, New York, Connecticut, Nevada, Texas, Hawaii, New Hampshire, Wisconsin, Minnesota

GOAL: Testing the impact of providing incentives to Medicaid beneficiaries who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors.

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Strong Start: Strategy 1

3 primary activities:

1. Promote Awareness – support broad-based awareness efforts in partnership with March of Dimes, American College of Obstetricians and Gynecologists and other organizations.

2. Spread Best Practices – building on efforts of Partnership for Patients to create measureable goals and provide technical assistance in testing and implementing a variety of strategies.

3. Promote Transparency – support efforts to collect performance data and measure success and continuous improvement.

GOAL: Test ways to encourage best practices and support providers in reducing early elective deliveries prior to 39 weeks.

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Strong Start: Strategy 2

• Testing 3 approaches to the delivery of enhanced prenatal care

• Targets women receiving Medicaid and at risk for having a preterm birth

• Up to $43 million in funding to 27 awardees (announced 2/15/13)

• Awards will be located in 32 states, the District of Columbia and Puerto Rico, and will serve more than 80,000 women enrolled in Medicaid or CHIP over the three intervention years

GOAL: Test effectiveness of prenatal care approaches to reduce preterm births for women covered by Medicaid or CHIP who are at risk for preterm births

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Health Care Innovation Awards

• 107 Projects Awarded in 2 Batches: 5/8 and 6/15

• Awards range from approximately $1 million to $30 million for a three-year period.

• Will impact all 50 states

• Nearly 3000 applications received

• Applications were accepted from providers, payers, local government, public-private partnerships and multi-payer collaboratives.

GOAL: Test a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement in communities across the nation.

Health Care Innovation Awards

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State Innovation Models

GOALS: • Partner with states to develop broad-based State Health Care

Innovation Plans

• Plan, Design, Test and Support of new payment and service and delivery models in the context of larger health system transformation

• Utilize the tools and policy levers available to states

• Engage a broad group of stakeholders in health system transformation

• Coordinate multiple strategies into a plan for health system improvement

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State Innovation Models Awardees

Model Testing States • Arkansas • Maine • Massachusetts • Minnesota • Oregon • Vermont

Model Pre-Testing States • Colorado • New York • Washington

Model Design States

• California • Connecticut • Delaware • Hawaii • Idaho • Illinois • Iowa • Maryland • Michigan • New Hampshire • Ohio

• Pennsylvania • Rhode Island • Tennessee • Texas • Utah

(Announced 2/21/13)

State Innovation Models

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Where Innovation is Happening

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