CMS Bundled Payment for Care Improvement Initiative Resource Materials November 2011
Table of Contents
Bundled Payment Glossary
3
Bundled Payment Overview
6
CMS Scoring Criteria
12
Draft Workplan
17
LOI Description
20
Bundled Payment for Care Improvement Initiative Glossary Bundled Payment – A single negotiated episode payment of a predetermined amount for all services (physician, hospital, and other providers) furnished during an episode of care. This could be paid prospectively or retrospectively. In contrast to the fee for service (FFS) payment, the bundled payment covers services furnished by multiple providers in multiple care settings. This differs from capitation or global payments in that the bundled payment is a single payment only for the specified episode, rather than for all care for a patient during a specific time period. CCN – CMS Certification Numbers – a unique number that CMS assigns to participating providers. Convener – An entity that can bring together multiple participating health care providers, such as a state hospital association or a collaborative of providers. For purposes of this initiative, a convener may be the applicant, but may be subject to special provisions. A risk bearing convener who also may receive payments from CMS can participate in the initiative as an awardee. A convener that is not able to bear risk may not receive payments from CMS but may participate in the initiative as a facilitator for participating awardee providers. Episode – The defined period of time during which all Medicare covered services required to manage the specific medical condition of a patient are groups and paid as a unit. Episodes that are subject to episode payment are identified by the episode anchor. The episode may include the episode anchor and can include a period of time both before and/or after the anchor. Episode Anchor – The event which triggers beneficiary inclusion in the episode. In Model 3, this is the initiation of post acute services at a participating organization (long term care hospital, skilled nursing facility, inpatient rehabilitation facility, or home health agency) within 30 days of beneficiary discharge from an acute care hospital stay for an agreed upon MS-DRG. Episode Reconciliation – A regular comparison of the total fee for service payment to providers for services included in the episode with the predetermined target price for the episode. If aggregate FFS payments exceed the predetermined target price, the awardee must repay Medicare. If aggregate fee for service payments are less than the predetermined price, the awardee will be paid the difference, which may be shared among the participating providers. Episode Target Price – The agreed upon total Medicare payment for the episode.
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Evidence based practice – The process of decision making about promoting health or providing care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment, along with the formulation of questions and testing of hypotheses. Facilitator – A convener who is participating in the Bundled Payments for Care Improvement Initiative as a partner with providers, but who does not assume financial risk or receive payment directly under an agreement with Medicare. Gain Sharing – Payments shared among providers that represent a portion of the gains achieved due to more coordinated, efficient, higher quality care. Under this project, CMS extends the concept to enable hospitals, post acute care providers, physicians, and nonphysician practitioners to all benefit from the gains achieved. Learning Health Care System – A health care system that is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care. Meaningful Use – The primary components of meaningful use include the use of the electronic system to achieve a specific important program goal, such as e-prescribing; the use of technology for electronic exchange of health information to improve the quality of care, or the use of technology to submit clinical quality and other measures. CMS definition of Meaningful Use is intended to be issued over a period of time until 2015. Only Stage 1 has been defined at this point. http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp Meaningful use includes both a core set and a menu set of objectives that are specific to eligible professionals or eligible hospitals and CAHs. For eligible professionals, there are a total of 25 meaningful use objectives. To qualify for an incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives. The remaining 5 objectives may be chosen from the list of 10 menu set objectives. For eligible hospitals and CAHs, there are a total of 24 meaningful use objectives. To qualify for an incentive payment, 19 of these 24 objectives must be met. o o
o o
There are 14 required core objectives. The remaining 5 objectives may be chosen from the list of 10 menu set objectives.
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Medical Home Model Demonstrations – Targeted, accessible, continuous and coordinated care to Medicare beneficiaries with chronic or prolonged illnesses requirement regular medical monitoring, advising or treatment. Demonstration models have been developed with federal qualified healthcare centers, state Medicaid agencies, and under several individual grants. Under the project, beneficiaries with chronic conditions can designate a single provider as their ‘health home’ in order to decrease fragmentation, confusion, and improve coordination of care. MS DRG – Medicare DRGs are designed to classify beneficiaries receiving hospital care into groups based on the ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and presence of complications or co-morbidities. Each classification has an accompanying payment rate for given hospitals, since patients in each category are thought to be similar and would be expected to use the same level of hospital resources. Physician Quality Reporting System – A CMS program that provides an incentive payment to eligible professionals who satisfactorily report data on quality measures for covered professional services provided to Medicare beneficiaries. http://www.cms.gov/pqrs/01_overview.asp? Post Episode Monitoring – A mechanism to detect those services/expenditures expected to be included in an episode of care that are furnished or paid outside of the episode (before or after), thereby potentially increasing total Medicare spending for services related to the episode. Typically this will compare the actual Medicare spending to historical baseline to detect overall increased expenditures despite the discount provided through the target price for the episode. Replicable – For this project, the ability to easily reproduce the same findings in a similar population or region with similar results. Risk Adjustment – A system that accounts for increased medical expenditures for a specified subset of beneficiaries who are associated with frailty and multiple co-morbid conditions. Scalable – For this project, the ability of a provider to accept growing numbers of beneficiaries for inclusion with the addition of resources - the ability of the provider to accept increased volume without impacting the contribution margin. Target Price – For the purpose of this project, a target price is the amount of reimbursement established by the applicant that includes a discount from the historical costs identified for a given MS DRG and represents the minimum savings goal expected during the demonstration.
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CMS Bundled Payment for Care Improvement Initiative Overview: Model 3 Program Goals: Payment innovation fostering improved coordination and quality through a patient centered approach. The project is in alignment with the Health and Human Services’ three part aim - better health for individuals, better health for populations, and lower growth in expenditures. The successful program will improve coordination across providers and health settings and deliver services that are guided by patient needs and wishes. Program design should include processes to continuously reengineer care to achieve better health, better care, and lower costs. This positively reinforcing cycle should lead to decreasing the cost of an acute episode of care and the associated post acute care while fostering quality improvement. The project will develop and test payment models that create extended accountability for three part aim outcomes and shorten the cycle time for the adoption of evidence- based care. CMS also expects to see creation of environments that stimulate rapid development of new evidence-based knowledge. Eventually chronic care models may be developed as well. Methods to accomplish the goals: Continuous re-engineering to deliver the three part aim Creating a virtuous cycle of continuously decreasing the cost of acute or chronic episode of care while fostering quality improvement Developing and testing payment models that create extended accountability for three part aim Shortening the cycle time for evidence based care Creating environments that stimulate rapid development of new evidence based knowledge – the learning health care system. Preparing to extend to chronic care design models
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What will the best proposals look like according to CMS? Affect broad categories of conditions Reach many beneficiaries Offer significant savings to Medicare Designed to be scalable and replicable by similar health systems Currently (or could rapidly be developed) to involve participation by other payers Are able to be implemented on aggressive time frames
CMS preferences will be provided to the following proposals: Applicants who have demonstrated meaningful use of health information technology or who have a minimum of 50% of their providers meeting the standards for meaningful use. Applicants proposing an episode definition longer than 90 days. Applicants with a higher rate of physician participation in PQRS and will have plans for greater physician involvement during the project. Applicants whose governing bodies have meaningful representation from consumer advocates, patients, and all participating provider types, and applications that include functional status in the proposed quality measures.
Additional Issues The program accomplishes its goal in different manner from the ACO program, because it works at the individual patient level, rather than the population level – which decreases the risk and operational complexity for the provider. Projects will not be limited by region or particular conditions or size, but will be prioritized based on scoring. CMS will look for the ability to rapidly replicate and scale so that the project can be used as a model very quickly. CMS will look forward to a broad geographic distribution of awardees. Each application will also be reviewed in light of the programs the applicant is already participating in or planning to participate – such as ACOs, medical home models, etc. CMS may adjust program requirements if programs overlap. Process Requirements CMS is allowing flexibility in health care delivery structure and flexibility in determining how payments will be made and allocated. The episode of care begins when the beneficiary who was discharged from the hospital with a qualifying condition accesses post acute services with a participating provider within 30 days, and the episode lasts a minimum of 30 days. Applicants will identify an episode of care that is characterized by specific conditions (MS-DRGs) and timeframe.
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Applicants may identify in their proposals methods to waive certain regulatory requirements – such as three day qualifying hospital stays or other requirements. Defining the episode of care The minimum expectations for the episode of care definition are noted above. The applicant will define the time period (Aging Services of Michigan requested data for up to 90 following the acute care episode). CMS encourages episode definitions that include all of the MS DRGs for the relevant clinical conditions that reflect the various complications and co-morbidities that may apply to Medicare beneficiaries. A list of the MS DRGs can be found in the Letter of Intent package. Proposed episode definitions that include multiple MS DRGs should use the same rate of discount across all DRGs in that episode definition. Or a proposal may include three DRGs for the same condition for a diagnosis without complication and/or co-morbidities, one with complications and or complications and one with major complications and or co-morbidities. For that scenario, a separate application table C1 for each MS DRG, using the same episode definition must be completed using the same parameters and services included. Applicants should applying the same rate of discount to each 2009 average cost per episode to determine your proposed target prices or bundled payment amounts. Research Data Assistance Center (ResDAC) contractor will provide limited technical assistance once applicants receive the data. The episode anchor is the post acute service initiated in a skilled nursing facility, inpatient rehabilitation facility, long term care hospital, or home health agency within 30 days of beneficiary discharge from an acute care hospital for an agreed upon MS-DRG. Episode begins on the date post acute services are initiated and will continue through a 30 day minimum. Episode definition must include all Part A services for related readmissions and all related Part B services (physician services and post acute services related to the episode anchor) furnished during the episode, including during related and unrelated admissions. CMS prefers episode definitions longer than 30 days to understand how care can be redesigned to transition better back into the community. Applicants can propose further definitions of the episodes, including beneficiary identification through MS DRGs designated as unrelated and excluded unrelated part b services (identified by ICD 9 diagnosis codes designation as unrelated. CMS expects to see reengineered care pathways using evidence based medicine, standardized care using checklists, and care coordination as part of the proposed model. Target Price Development A proposed target price must be set by the applicant by applying a discount to total costs for a similar episode as determined from historical data. All Medicare FFS payments will be made at Page 8 of 26
the usual rates. When determining the target price, applicants should include outlier payments in their calculations; outlier payments will be included in the episode reconciliation calculation when determining whether the awardee has met the target price. Applicants should also factor expected readmissions during the episode period into their financial proposals. The target price will exclude medical education and disproportionate share payments for hospital readmissions in Model 3 and when calculating actual expenditures for comparisons with the target price. Total payments will be compared and reconciled with the target price. Participating providers will be able to share in the savings identified beyond the target price. Providers will use 2009 data for historical payments and propose payments in calendar year 2009 dollars. CMS will trend proposed target prices to calendar year 2012 dollars for the final agreements. The target price will be further trended forward in subsequent years of the performance period. The negotiated discount reflected in the target price will remain constant, while CMS will index the target price each year to FFS payment changes as the systems are updated (positively or negatively) annually according to the applicable standard PFS and post acute provider prospective payment system updates and other adjustments that apply. CMS will consider applicant proposals around risk adjustment but applicants must include the methodology and plan for update risk adjustment on a yearly basis based on new information. Awardees will be financially liable for Medicare payments in aggregate beyond the predetermined target price, including care for included beneficiaries that has been delivered by providers who are not directly participating in testing the episode payment model. If a provider agrees to participate, then all providers sharing the same CCN must participate using the same parameters. Care unrelated to the specific selected health condition will be paid separately. Gain Sharing Applicants can submit proposals that allow gain sharing - payments made to specific providers as a result of collaborative efforts to improve quality and efficiency. Waivers to fraud and abuse laws in Title XI and XVIII of the Older Americans Act would be included in the terms of the final agreements. Gain sharing may also be considered for private pay patients – but may implicate other federal and state fraud and abuse laws. Quality Requirements Applicants must plan and implement quality assurance and improvement activities as a condition of participation, report specific quality measures, and propose strong patient protections that preserve beneficiary choice in seeking care from the provider of their choice.
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CMS will monitor clinical quality, patient experience, and outcomes of care throughout the demonstration. Applicants should include a strict quality monitoring program as part of the application and commit to providing care at or above what is currently experienced. CMS will terminate the project if care suffers or costs and outcomes suffer in the period following the episode of care as well. Proposals will be graded on ability to provide beneficiaries with information about participation in this initiative, as well as proposed plans for beneficiary engagement and inclusion in redesigning care. Awardees must notify beneficiaries of their involvement in the bundled payments for care initiative and explain the potential implications. CMS may require the use of the CARES tool, an assessment that defines needs across settings; and may require other specific quality measures. In addition, CMS has the expectation that applicants utilize a Health Care Learning Network Model. Beneficiary Inclusion Dual eligibles may be included unless they are part of other programs, such as Medicare Advantage Plans or they have been diagnosed with end-stage renal disease. If a dual eligible receives Medicare covered care for an included condition from a participating provider, the episode of care will be included in the demonstration. Plans for any dual eligibles should include engagement of the state Medicaid agency toward better coordination of care. CMS will look favorably on applications that demonstrate partnership with the state Medicaid programs (private payers, or multi payer collaboratives) to redesign care. Medicaid providers may be able to participate if their state Medicaid program partners with providers. States can apply as conveners. When a provider agrees to participate, the initiative includes all Medicare beneficiaries who receive care from that provider and who meet the episode definition. Providers, physicians can participate in more than one project. CMS may also waive Medicare coinsurance and copayments for beneficiaries included if a compelling explanation is included in the model design.
Historical Data Use CMS will provide Medicare data as part of the proposal request and the data will include beneficiary level claims with masked identifiers. The data set will include the potential applicant’s geographic region and will include at a minimum Part A and Part B payment amount by MS DRG or HCPCS, services rendered, dates of service, diagnosis and procedure codes, and institutional provider as well as beneficiary age and sex. No hospice or part D files will be available.
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Applicants/Awardees can share information that is stripped of CMS data. Data files will have a .dat extension and will be in fixed column ASCII files format. Sample episode definitions and summary data (for 18 samples) supporting them will be made available separately from the LDS files. Applicants will not need to submit a research packet to access this data and more information will be available on the bundled payment for care website by early November. Applicant Expectations CMS anticipates that applicants will have experience with cross provider care improvement efforts of this type and either have already begun to redesign care and enter into payment agreements that include financial and performance accountability for episodes or plan to do so. For applicants less ready to engage in care episode redesign, CMS will provide substantial learning network activity around fundamental components of care episode redesign and how to access and protect data.
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Bundled Payment Proposal – CMS Grading Criteria
Model Design Episode Definition Transparent – clear and reasonable Replicable – a project model that is not unique to a given population Scalable – able to accept increased volume without impacting the contribution margin Successfully aligns awardee and provider incentives to improve care/protects consumers Episodes include a larger number of beneficiaries and targets most significant avoidable costs Affects a broad range of categories of clinical conditions Episode definitions longer than 30 days post-hospital discharge Provider Engagement and participation Strong evidence of physician commitment to align incentives through bundled payments Letters of agreement from high numbers of physicians Letters of agreement from high percentage of participating physicians Strong evidence of other participating provider commitments Letters of agreement from Bundled Payment Participating organizations Care Improvement Aspects of care that will be redesigned Plans for how care will be redesigned to improve care Capacity and readiness to improve care
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20 Points
Design for gain sharing (Model Design, continued) (Payments made by providers to physicians and other practitioners as a result of collaborative efforts) How will gain sharing support redesign to achieve improved quality/experience/cost savings Describe the methodology for gain sharing – who will be included, what criteria and quality standards Will be used to determine gains haring How will we ensure that physicians and non-physicians will not limit or reduce services that are medically necessary to a patient entitled to benefits under Medicare How will we document gain sharing so that it is transparent and auditable How will ensure that physicians will not select patients for the project based on ability to gain share How will we communicate/allow physicians to opt out of gain sharing What quality thresholds will be required to participate in gain sharing How will we monitor that quality requirements are met by providers participating in gain sharing Throughout the project What are the minimum quality thresholds What is the process for monitoring quality and quality improvement during the project period What set of metrics for improving quality of care during the project period How will physicians become eligible or ineligible to participate in gain sharing Demonstrate that payments are not based on volume or value of referrals or business generated between Providers – payments can be based on achieved savings Demonstrate that payments cannot be more than 50% of the amount normally paid for cases Include a comprehensive plan about how financial rewards will be distributed
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Financial Model Overall Savings to Medicare Have we provided the highest reasonable discount to Medicare Have we provided safeguards for quality care Is the description of the discount, expected volume, expected target price Comprehensive Valid Transparent Replicable Risk Adjustment Is how we will adjust for risk included? Are any plans for risk adjustment Comprehensive Valid Transparent Replicable Anticipated actions that will result in lower spending Planned care improvement interventions described result in Improved efficiency Cost savings Reduced Medicare spending
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40 Points
Quality of Care and Patient Centeredness Proposed mechanisms to improve care How will redesigned care, coordination of care across settings lead to improved quality and experience How will HIT enable quality measurement, reporting and feedback How will EHRs be used How will patient records be exchanged across providers and settings to ensure coordination Have we included tools to collect information and assess functional status into the application (CARES??) Proposed Quality Measures Have we included all the required quality measures listed in RFA What other quality measures will be used. Are they Comprehensive meaningful Evidence based Credible How will we ensure that quality will not decrease Quality performance Patient functionality Patient and caregiver experience Care coordination Transitions Patient Safety Have we included physicians with high rate of participation on the PQRS How will we ensure physicians not engaged with PQRS will start to use it How will we ensure that measures of quality outcomes will be used to continuously improve project operations and care Beneficiary Protections What is our comprehensive plan for beneficiary protection Freedom of choice of providers Notification Engagement Education Page 15 of 26
25 points
Organizational Capabilities, Prior Experience, and Readiness Financial Arrangements How have we demonstrated an ability to bear financial risk Have we detailed how financial rewards will be distributed Is the plan transparent Commitment and credentials of executives and governing bodies Have we demonstrated strong leadership support Have we demonstrated that leaders are aligned with the applicants vision and mission Does our governing body include meaningful representation from consumer advocates, patients, all Participating provider types/organizations Success and Readiness to participate What prior successes have we demonstrated across providers Have we demonstrated readiness to launch the program Have we demonstrated we are meaningful users of HIT or who have a minimum of 50% of providers Meeting the standard for meaningful use Can we exchange patient summary records with relevant providers to ensure care coordination, Medication reconciliation, and prevention of unnecessary hospitalizations Have we provided a comprehensive and credible implementation plan, including a timeline Partnerships Have we demonstrated partnership with State Medicaid programs Private payers Multi-payer collaboratives Have we fostered participation of a large numbers of providers Affect large numbers of beneficiaries in an organized and efficient manner
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15 Points
Bundled Payment Initiative Work Plan
Proposed Start
Milestone/Task Project Review Identify small committed workgroup including roles and responsibilities Review project requirements along with risks and benefits Review CMS demonstration projects - issues and outcomes Review all materials issued to date Develop a list of questions and issues to address with CMS Schedule first task force meeting
Determine opportunities for outcomes and efficiencies Review system challenges and current Michigan projects to address barriers Care Transitions Project MI Staar Program Clinical Coverage Models General Lit review on rehospitalizations and fragmented care Staff training and expertise Electronic medical record systems Evidence based care development for possible clinical condtions and methods to identify and implement EBC rapidly Services that could be shared to promote regional efficiencies Identify relationship of improved coordination for post acute care to long term care provision Document and develop a logic model that shows potential efficiencies and supporting rationale Review proposed participants current system design, programs, relationships and outcomes Send a letter to included providers in LOI Identify current provider relationships especially with hospitals and physicians for proposed conditions Review available outcome data for the particpating providers and determine opportunities Review cost and pricing issues for individual participating providers Identify individual provider best practices and opportunities for sharing/implementing regionally
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Proposed End
11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/21/2011 11/15/2011
12/1/2011 11/23/2011 11/28/2011 11/28/2011 11/18/2011 11/21/2011 12/1/2011
11/10/2011 11/10/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011
12/28/2011 11/30/2011 11/18/2011 11/18/2011 11/18/2011 11/30/2011 11/30/2011 11/30/2011
11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011 11/18/2011
11/30/2011 11/30/2011 11/30/2011 11/30/2011 11/30/2011 11/18/2011
11/18/2011 11/18/2011 11/18/2011 11/18/2011
11/30/2011 11/30/2011 11/30/2011 11/30/2011
Bundled Payment Initiative Work Plan Develop proposed structure for statewide steering committee to guide regional networks Determine an organizational structure that provides oversight to potential regional network entities Determine regional network entity organization and legal issues/ramifications Identify regional ability to incur risk and demonstrate risk taking ability to CMS Determine opportunities to work with State entities - Medicaid, etc and develop communications plan Schedule Legislative meetings Schedule meetings with Governor's office Develop specific project activities designed to foster efficiencies and outcomes Continuously re-engineering/rapid cycle improvement processes Creation of a learning network Develop care coordination model that includes resources and plans for access to clinical oversight Identify communication plan for the network Develop shared services plan Establish the model for statewide and regional network management
Develop parameters for bundled payment project
12/1/2011 12/14/2011 12/1/2011 12/14/2011 12/1/2011 12/14/2011 12/1/2011 12/14/2011 12/1/2011 12/14/2011 12/14/2011 12/1/2011 12/1/2011 12/1/2011 12/1/2011 12/1/2011 12/1/2011 12/28/2011
12/14/2011 1/1/2012 1/1/2012 12/28/2011 12/28/2011 12/28/2011 12/28/2011 12/28/2011 12/28/2011 12/28/2011
11/23/2011 1/31/2012
Review 18 sample episode definitions and data analysis Review CMS data provided Review model for regional networks and identify need for additional data Determine the episode of care based on previous analysis Consider dual eligible models with lengthened PA periods and Medicaid involvement Determine conditions most likely to provide savings opportunities and outcome improvement
11/23/2011 12/1/2011 12/1/2011 12/1/2011 12/14/2011 12/1/2011
11/23/2011 12/16/2011 12/16/2011 1/4/2012 1/4/2012 12/28/2011
Determine what evidence based models apply to selected conditions and how they can be implemented
12/1/2011 12/28/2011
Determine how many beneficiaries can effectively be reached and potential Medicare/ provider savings
12/1/2011 12/28/2011
Determine whether any potential project outcomes might not be pertinent to other regions/projects Determine pricing plans Determine opportunities based on CMS data and any additional data used Determine entities to be included Develop a communications/engagement plan for potential providers and consumers Page 18 of 26
12/1/2011 12/14/2011 12/14/2011 12/1/2011 12/1/2011
12/28/2011 12/28/2011 12/28/2011 12/21/2011 12/21/2011
Bundled Payment Initiative Work Plan Determine quality assurance monitoring plan Determine CMS minimum reporting expectations Develop learning network structure Rapid cycle improvements based on evidence based practices Develop overall QI plan
12/1/2011 1/31/2012 12/1/2011 12/15/2011 1/2/2012 1/31/2012 1/2/2012 1/31/2012 1/2/2012 1/31/2012
Develop the application
2/1/2012 2/24/2012
Confirm and document the final proposed model Develop the application workplan Complete application
2/1/2012 2/1/2012 2/1/2012
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2/24/2012 2/24/2012 2/24/2012
Attachment A Centers for Medicare & Medicaid Services (CMS) Research Application Guidelines for Requesting Limited Data Sets 1. Introduction Title – Aging Services of Michigan Bundled Payment Initiative Purpose – Aging Services of Michigan seeks to use the CMS Bundled Payments for Care Improvement Initiative to further its work toward developing regional provider networks of premier, not for profit, mission based providers of post acute and acute care services. For the past 18 months, our Association has been developing a collaborative group of providers and other experts and agencies to address fragmentation/coordination issues and to provoke improved outcomes in post acute and long term supports and services. These collaborating agencies include a wide range of experience and expertise and will work toward supporting member providers within 3-4 regions across the state in ways that will provoke better consumer outcomes and cost efficiencies. Our Collaborative Partners include post acute care providers as well as: Health Management Associates: Dr. Vernon Smith, national Medicaid expert and Janet Olszewski – former Director of the Michigan Department of Community Health The Michigan Peer Review Organization Dykema Gossett PLLC – Phyllis Adams Michigan Association of Area Agencies on Aging, Mary Ablan Management and Network Services, LLC – Health plan data experts Michigan Hospice and Palliative Care Organization – Lisa Ashley LeadingAge – Our National Association Omnicare – A national pharmaceutical company Agility Health – Therapy services company These partners have come together to develop a plan that will: Utilize a regional provider network to improve communication and coordination of care across services and settings – reducing duplication of services and improving outcomes; Develop a set of evidence-based care pathways that will standardize best practices of care for a given set of conditions across the providers within the network; Develop and refine the clinical nursing and other professional skills needed in post acute care to improve early identification and intervention; Define and develop a set of performance measures across each setting and provider type that will adequately describe quality outcomes and that will support a culture of safety;
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Share support services that will produce efficiencies of scale that will offer a competitive advantage in terms of cost and quality for a regional network of providers; and Provide a person-centered approach to clinical decision-making. Success of this project will significantly improve the overall quality of life and care for participants through streamlined health care operations, improved communication and coordination, and ongoing rapid cycle improvement. The project staff will need access to Medicare Claims Data in order to develop reimbursement targets and to establish a baseline of cost for several given conditions (MS-DRGs). We will utilize one of our Collaborative Partners, Health Management Associates to assist with data analysis.
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2. Project Issues and Methods Key issues to be studied - the following is a list of the DRGs and type of episodes we wish to explore with the data, along with a list of providers who will be involved in the project MSDRG 056 057 064 065 066 067 068 177 178 179 189 190 191 192 193 194 195 280 281 282 291 292 293 469 470 480 481 482 689 690
Title Degenerative Nervous System Disorders w MCC Degenerative Nervous System Disorders w/o MCC Intracranial Hemorrhage or Cerebral Infarction w MCC Intracranial Hemorrhage or Cerebral Infarction w CC Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC Nonspecific CVA and Precerebral Occlusion w/o infarct w/MCC Nonspecific CVA and Precerebral Occlusion w/o infarct w/o MCC Respiratory infections and inflammations w MCC Respiratory infections and inflammations w CC Respiratory infections and inflammations w/o CC/MCC Pulmonary edema and respiratory failure Chronic obstructive pulmonary disease w MCC Chronic obstructive pulmonary disease w CC Chronic obstructive pulmonary disease w/o CC/MCC Simple pneumonia and pleurisy w MCC Simple pneumonia and pleurisy w CC Simple pneumonia and pleurisy s/o CC/MCC Acute Myocardial infarction w MCC Acute Myocardial infarction w CC Acute Myocardial infarction w/o CC/MCC Heart Failure and Shock w MCC Heart Failure and Shock w CC Heart Failure and Shock w/o CC/MCC Major Joint Replacement or reattachment wMCC Major Joint Replacement or reattachment s/o MCC Hip and Femur Procedures w MCC Hip and Femur Procedures w CC Hip and Femur Procedures w/o CC/MCC Kidney and Urinary Tract Infections w MCC Kidney and Urinary Tract Infections w/o MCC
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Collaborative Partner Providers Genesys Health System Genesys Convalescent Mid Michigan Hospital System Midland Mid Michigan Gladwin Pines Mid Michigan Stratford Village UMRC Chelsea Retirement Community Luther Manor Saginaw Lodge at Maple Creek Lakeview Lutheran Manor EHM Saline EHM Sterling Heights Glacier Hills Masonic Pathways Providence Zeeland Resthaven Porter Hills Henry Ford Village Lutheran Home Frankenmuth Lutheran Home Monroe Lutheran Home Livonia
CCN 230197 230171 230222 235485 235608 235021
235250 235458 235094 235238 235473 235223 235020 235347 235378 235310 235593 235269 235274 235587
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First we will identify each episode in the data by finding each inpatient discharge with a target DRG followed by the initiation of a SNF, IRF, HHA, or LTCH service within 30 days of the discharge. o The begin date of the episode will be defined as the begin date of the SNF, IRF, HHA, or LTCH service. o The end date of the episode will be defined as 90 days after the episode begin date. o The type of episode will be defined by the DRG and the demographic characteristics of the patient. o Admissions that fall within a previous episode will not be considered a new episode; those admissions will be considered part of the previous episode; the begin date, end date, and type of episode for the previous episode will not be changed in light of the existence of the subsequent admission. o All services qualifying to be bundled and falling within an episode will be considered part of the episode; the number of and payment for services will be summarized by length of time from begin date of episode, type of service, type of provider, type of diagnosis for the service and type of episode. o We will then look at these summaries to identify the range of costs for each MS-DRG, groups of common MS-DRGs, and associated beneficiary characteristics to determine risk, potential for improved cost effectiveness, and ultimately payment targets for MS-DRGs selected for inclusion in the project. o There are no proprietary tools used for analysis. 3. Data Management Safeguards Infrastructure: To ensure the privacy and confidentiality of data for this project, Health Management Associates will store the "raw" SAF data at one location, which is the office of Dennis Roberts, located at 120 N. Washington Square, Suite 705, Lansing, Michigan 48933. Mr. Roberts has been designated by the Collaborative as the custodian of the data and has signed the Data Use Agreement. Mr. Roberts' office is located in a suite in an office building which is secured by physical door locks after regular business hours. The suite is physically locked at all times when the suite is not occupied. The SAF data will be uploaded to a personal computer (PC) in Mr. Roberts' office. The PC runs on Windows 7 Professional. The folder on the PC containing the SAF data will be accessible only by Mr. Roberts. The PC is configured to lock after 15 minutes of inactivity and can only be unlocked by Mr. Roberts or the company's information technology support staff. The PC is connected to a local area network (LAN) but the SAF data will not be in a shared folder so will not be accessible by anyone over the LAN. Since the LAN
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and PC are behind multiple firewalls, monitored regularly, and the folder containing the SAF data will only be accessible by Mr. Roberts, the risk of unlawful penetration is not a significant data safeguard concern. The SAF data folder will not be part of the standard backup of the PC. This will prevent any data from being stored on the LAN file server or its backup tapes. Instead, manual backups of the folder will be performed by Mr. Roberts. These backups will include data processing procedures, summary files, and any other files that would be required to rebuild the database from original CDs/DVDs/ USB hard drive in the event the PC crashes. Offsite copies of these backups will be encrypted using AES 256 encryption and a long password. HMA has offices in several states and uses a secure wide area network (WAN), with a private frame relay and secured lines, to enable staff in multiple offices to work together on projects. The other HMA staff members participating in this study are identified in the Key Personnel Section and they have signed Addenda to the Data Use Agreement. As they are not all located in the Lansing office, they will use the WAN to access data tables that Mr. Roberts develops from the SAF data. None of these staff will have access to the "raw" SAF data. These data tables will be placed in a secure project folder on the WAN to which only the identified staff will have access. No data tables will be transmitted by unsecured telecommunications. Collaborative staff for this project will also have access to data tables, but not the SAF data, which will be shared via a secure File Transfer Protocol (FTP) site. Neither the SAF data nor any resulting data tables will be physically moved or transmitted in any way from the referenced sites at HMA without prior written approval from CMS. Should there become a need to change the designated staff or collaborative member that will ensure safe storage of the ‘raw’ data, Aging Services of Michigan will communicate and consult with CMS to obtain written approval and update our data use agreement. Transmission of these summary files will be accomplished using HMA's secure FTP or SharePoint sites (see above). Procedures: Only the Data Custodian will have access to the raw database. Only authorized personnel will have access to PII and PHI. Only summary files will be shared with other authorized personnel on the project. These files generally contain no, or very limited, PII or PHI. Summary and analytical files will be shared using HMA's secure FTP as described above.
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4. Key Personnel The following staff will have access to the limited data set files: Dennis Roberts, Health Management Associates, data analysis Dr. Larry Petroskey, Evangelical Homes of Michigan, data analysis Deanna Ludlow Mitchell, Aging Services of Michigan, data analysis 5. Dissemination/Implementation Data will be analyzed by MS-DRG to determine the types and amounts of services used by beneficiaries following an acute hospitalization. All information will be reviewed in summary form, with aggregated findings based on condition. No individual level data will be reported. Data reports will include the number of beneficiaries in specific MS-DRG categories or groups, types and number of services used, and cost, and by region if appropriate. 6. Proprietary Information There is no proprietary information included in this request.
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