CMS Innovation

Dr. Steven FarmerSenior Advisor and Senior Medical Officer,Center for Medicare and Medicaid InnovationMay 6, 2019

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Disclaimers

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 publication 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 referenceThe 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 presentation.

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Presentation Overview

• CMS Innovation Center Overview• Model Development• Policy Direction• ET3 Model• Acute Care Models

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CMS INNOVATION CENTER OVERVIEW

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The CMS Innovation Center Statute

“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”

Three scenarios for success from Statute:1. Quality improves; cost neutral2. Quality neutral; cost reduced3. Quality improves; cost reduced (best case)

If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking

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CMS support of health care will result in patient-centered, market-driven reforms that drive quality and improve outcomes

Key characteristics§ Producer-centered§ Incentives for volume§ Unsustainable§ Fragmented Care

Key characteristics§ Patient-centered§ Incentives for outcomes§ Sustainable§ Market-driven§ Coordinated care

Public and Private sectors

Evolving future stateHistorical state

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The Innovation Center portfolio aligns with broader CMS goals

Deliver Care

§ Learning and Diffusion‒ Partnership for Patients ‒ Transforming Clinical Practice

§ Health Care Innovation Awards§ Integrated Care for Kids (InCK) Model§ Accountable Health Communities

§ State Innovation Models Initiative‒ SIM Round 1 & SIM Round 2‒ Maryland All-Payer Model‒ Pennsylvania Rural Health Model‒ Vermont All-Payer ACO Model

§ Million Hearts Cardiovascular Risk Reduction Model

Distribute Information

§ Information to providers in CMMI models § Shared decision-making required by many models

Pay Providers

§ Accountable Care ‒ ACO Investment Model‒ Pioneer ACO Model‒ Medicare Shared Savings Program (housed in Center for

Medicare)‒ Comprehensive ESRD Care Initiative‒ Next Generation ACO

§ Primary Care Transformation‒ Comprehensive Primary Care Initiative (CPC) & 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‒ Frontier Community Health Integration Project

‒ Medicare Diabetes Prevention Program Expanded Model§ Bundled payment models

‒ Bundled Payment for Care Improvement Models 1-4‒ BPCI Advanced‒ Oncology Care Model‒ Comprehensive Care for Joint Replacement

§ Initiatives Focused on the Medicaid Population ‒ 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 D

‒ Medicare Advantage Value-Based Insurance Design Model‒ Part D Enhanced Medication Therapy Management

Test alternative payment models

Support providers and states to improve the delivery of care

Increase information available for effective informed decision-making by consumers and providers

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Innovation Center all-inclusive portfolio

• ACO Investment Model• Accountable Health Communities Model• Advance Payment ACO Model• Advanced Primary Care Initiatives• Bundled Payments for Care Improvement Models 1-4• Bundled Payments for Care Improvement (BPCI) Advanced• Cardiac Rehabilitation (CR) Incentive Payment Model• Community-based Care Transitions Program• Comprehensive Care for Joint Replacement Model• Comprehensive ESRD Care Model• Comprehensive Primary Care Initiative • Comprehensive Primary Care Plus + Round 2• Emergency Triage, Treat, and Transport (ET3) Model• Financial Alignment Initiative for Medicare-Medicaid Enrollees• FQHC Advanced Primary Care Practice Demonstration• Frontier Community Health Integration Project Demonstration• Graduate Nurse Education Demonstration• Health Care Innovation Awards: Round 1, Round 2• Health Plan Innovation Initiatives• Home Health Value-Based Purchasing Model• Independence at Home Demonstration• Initiative to Reduce Avoidable Hospitalizations among Nursing Facility

Residents• Initiative to Reduce Avoidable Hospitalizations among Nursing Facility

Residents: Phase Two• Innovation Advisors Program• Integrated Care for Kids (InCK) Model• Maryland All-Payer Model• Maryland Total Cost of Care Model• Medicaid Emergency Psychiatric Demonstration• Medicaid Incentives for the Prevention of Chronic Diseases Model• Medicaid Innovation Accelerator Program• Medicare Acute Care Episode (ACE) Demonstration

• Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

• Medicare Advantage Value-Based Insurance Design Model• Medicare Care Choices Model• Medicare Coordinated Care Demonstration• Medicare Diabetes Prevention Program Expanded Model• Medicare Health Care Quality Demonstration• Medicare Hospital Gainsharing Demonstration• Medicare Imaging Demonstration• Medicare Intravenous Immune Globulin (IVIG) Demonstration• Million Hearts• Million Hearts: Cardiovascular Disease Risk Reduction Model• Multi-Payer Advanced Primary Care Practice• Next Generation ACO Model• Nursing Home Value-Based Purchasing Demonstration• Oncology Care Model• Part D Enhanced Medication Therapy Management Model• Partnership for Patients• Pennsylvania Rural Health Model• Physician Group Practice Transition Demonstration• Physician Hospital Collaboration Demonstration• Pioneer ACO Model• Private, For-Profit Demonstration Project for the Program of All-Inclusive Care

for the Elderly (PACE)• Regional Budget Payment Concept• Rural Community Hospital Demonstration• Specialty Practitioner Payment Model Opportunities• State Innovation Models Initiatives• Strong Start for Mothers and Newborns Initiatives• Transforming Clinical Practice Initiative• Vermont All-Payer Model

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Accountable Care Organizations: Participation in Medicare ACOs growing rapidly

§ 561 ACOs (of which 120 are risk-bearing) have been established in the MSSP, Next Generation ACO and Comprehensive ESRD Care Model programs*

§ This includes 85 more ACOS in 2017 than in 2016. covering 12.3 million assigned beneficiaries.§ These ACOs together cover 12.3 million assigned beneficiaries.

ACO-Assigned Beneficiaries by County**

* January 2016** Last updated April 2015

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CMS has engaged the health care delivery system and invested in innovation across the country

Models run at the state levelSites where innovation models are being tested

Source: CMS Innovation Center website, December 2017

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CMS Innovation Center’s range of impact

Beneficiaries touched

CMS Innovation Center models impact over 18M beneficiaries1,2 in all 50 states

Providers participating

Over 200,000 health care providers and provider groups2 across the nation are participating in CMS Innovation Center programs

1 Includes CMS beneficiaries (i.e., individuals with coverage through Medicare FFS, Medicaid, both Medicare and Medicaid (as Medicare-Medicaid enrollees), CHIP, and Medicare Advantage) and individuals with private insurance, including in multi-payer models2 Figures as of September 30, 2016

Source: Innovation Center Report to Congress, December 2016

> 18 million

> 207,000

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ProjectedHistorical

Gap between growth in federal Medicare spending, GDP growth and national health expenditure growth

Medicare growth has fallen below GDP growth and national health expenditure growth since 2010 due, in part, to CMS policy changes and new models of care

SOURCE: CMS Office of the Actuary National Health Expenditure Data (2014-2024 projections)

Average growth rate (2010−2014)

§ Medicare/beneficiary: 1.3%

§ GDP / capita: 3.3%

§ National Health Expenditure/capita: 3.7%

-3%

-2%

-1%

0%

1%

2%

3%

4%

5%

6%

7%

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Growth rate: US real per-capita GDP Growth rate: per capita national health expenditure

Growth rate: federal Medicare spending per enrollee

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MODEL DEVELOPMENT

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Model Development Process

Requests for Information (RFI)

How to Design an APM Toolkit

Consumer, Payer, Provider, Clinician

meetings, and roundtablesNotice and comment

rulemaking

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Model Life Cycle Framework

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POLICY DIRECTION

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New Direction - CMS Innovation Center Request for Information (RFI)

The RFI seeks broad input related to a new direction for the CMS Innovation Center that will promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, and improve outcomes.

The administration plans to launch models in several focus areas:

Guiding Principles

• Choice and competition in the marketplace

• Provider choice and incentives

• Patient-centered care

• Benefit design and price transparency

• Transparent model design and evaluation

• Small scale testing

• Expanded Opportunities for Participation in Advanced APMs• Consumer-Directed Care & Market-Based Innovation Models• Physician Specialty Models

• Physician-Focused Payment Model Technical Advisory Committee (PTAC) Recommended Models

• Prescription Drug Models• Medicare Advantage (MA) Innovation Models• State-Based and Local Innovation, including Medicaid-focused

Models• Mental and Behavioral Health Models• Program Integrity

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Innovation Center – 2019 Looking Forward

We are focused on:

Ø Implementation of Models

Ø Monitoring & Optimization of Results

Ø Evaluation and Scaling

Ø Integrating Innovation across CMS

Ø Portfolio analysis and launch new models to round out portfolio

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Ø Eliminate patient harm

Ø Engage in accountable care and other alternative payment contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost

Ø Invest in the quality infrastructure necessary to improve

Ø Focus on data and performance transparency

Ø Help us develop specialty physician payment and service delivery models

Ø Test new innovations and scale successes rapidly

Ø Relentlessly pursue improved health outcomes

What can you do to help our system achieve these goals?

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EMERGENCY TRIAGE, TREAT, AND TRANSPORT (ET3) MODEL

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Emergency Triage, Treat, and Transport (ET3) Model

Increase efficiency in the EMS system to more readily respond to high-acuity cases

Provide person-centered care and give beneficiaries greater control of their care

Encourage appropriate utilization of services to meet health care needs effectively

The ET3 Model provides greater flexibility to ambulance care teams responding to 911 calls, aimed at reducing expenditures while preserving or enhancing quality of care for beneficiaries

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Request for Applications anticipated Spring 2019Notice of Funding Opportunity anticipated Late 2019

Goals:

Appropriate care, at the right time, in the right place

Treatment On Scene

Hospital

Alternate Location

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ACUTE CARE MODELS

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The bundled payment model targets 48 conditions with a single payment for an episode of care

Ø Incentivizes providers to take accountability for both cost and quality of care

Ø Four Models - Model 1: Retrospective acute care hospital stay only- Model 2: Retrospective acute care hospital stay plus post-acute care- Model 3: Retrospective post-acute care only- Model 4: Prospective acute care hospital stay only

§ 261 Awardees and 983 Episode Initiators as of July 2017

Bundled Payments for Care Improvement is also growing rapidly

§ Duration of model is scheduled for 3 years:§ Model 1: Awardees began Period of Performance in

April 2013§ Models 2, 3, 4: Awardees began Period of

Performance in October 2013

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Spotlight: Bundled Payments for Care Improvement Initiative Model 2 –St. Mary Medical Center in Langhorne, PA

St. Mary’s Medical Center is a 373 bed, Acute Care Hospital testing the Congestive Heart Failure (CHF) clinical episode since January 1, 2014

• Focused on reducing preventable hospital readmissions through transitional nurse assistance with medical, behavioral, psychological, social, and environmental factors

• Monthly meetings with top 10 Skilled Nursing Facility partners to share quality metrics data and provide education to Skilled Nursing Facilities staff

• Established physician-led interdisciplinary committee to improve physician engagement in care redesign efforts

• Transition nurse service expanded to provide assistance to all CHF Medicare Beneficiaries

Care Redesign Efforts under the BPCI Initiative

A Beneficiary Success Story71 year old patient with CHF, CABG, sleep apnea with heavy alcohol and drug abuse history, who was estranged from family and lived alone, had no readmissions or ED visits post discharge during 90 bundle or 6 months after clinical episode concluded

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Bundled Payment for Care Improvement Advanced (BPCI Advanced)

BPCI Advanced is a voluntary bundled payment model that qualifies as an Advanced Alternative Payment Model (Advanced APM) with payment tied to performance on quality measures. • Runs October 1, 2018 through December 31, 2023• Single payment and risk track, with a 90-day episode period

– 29 Inpatient Clinical Episodes– 3 Outpatient Clinical Episodes– Preliminary Target Prices provided prior to the start of the Performance Period

Who can participate?– Convener Participants (Medicare enrolled or non-Medicare enrolled providers)– Non-Convener Participants (Medicare enrolled providers only)

Who are the Episode Initiators?– Acute Care Hospitals (ACHs)– Physician Group Practices (PGPs)

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BPCI Advanced Tests a Different Payment Approach

Shifts emphasis from individual servicestowards a coordinated clinical episode

Establishes an “accountable party”

Clinical episodes are assessed on the quality and cost of care

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BPCI Advanced is Different Than BPCI

Streamlined design • One model, 90-day episode period

• Single risk track

• Inpatient and Outpatient episodes

• Preliminary target prices provided in advance

• Payment tied to performance on quality measures

Greater focus on physician engagement and learning

Designed as an Advanced APM under the Quality Payment Program

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Questions?