2013 Bundled Payments / QIP Presented by John Greenacre

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1 2013 Bundled Payments / QIP Presented by John Greenacre

2 Objectives List at least 3 of the 2013 Proposed ESRD PPS regulations Review the 2013 and 2014 Final QIP changes Review 2015 and future Proposed QIP changes Possible changes in the TIME system for the 2013 ESRD PPS and 2015 QIP changes

3 CMS Dates to Remember July ESRD PPS Proposed rule was published 2015 Proposed QIP requirements was published in July 2012 Mid-November ESRD PPS Final rule is expected 2015 Final QIP requirements is expected

4 2013 Proposed ESRD Bundle Changes

5 2013 Bundle Factor changes Blended Facilities in 2013 Reimbursement will be 75% of the full ESRD PPS (bundled) amount 25% of the basic case-mix adjusted composite payment amount 2013 is the last year for basic case-mix (blended) payment 2014 We All Bundle

6 2013 Bundle Factor changes Updated Wage Index Factor * Look at Composite Base Rate ESRD PPS Base Rate Wage Floor Index * Amounts may change between proposed version of the regulations and final version of the regulations

7 2013 Outlier Policy Changes Factor * Medicare Allowable Payments (MAPs) for Pediatric Patients Medicare Allowable Payments (MAPs) for Adult Patients Fix Dollar Loss Amount for Pediatric Patients Fix Dollar Loss Amount for Adult Patients * Amounts may change between proposed version of the regulations and final version of the regulations

8 1 percent Outlier Policy The target of 1% not achieved in 2011 Only 0.52% of total payments Reduction in 2013 amounts should raise outlier payments to the 1% of total payments target

9 Separately Billable Changes Daptomycin Allow to be separately billable when Furnished to treat a non-esrd related condition (with supporting ICD-9 diagnosis) AY CPT modifier Alteplase and Other Thrombolytics CY 2012 were excluded from outlier calculations CY 2013 will not be considered eligible for separate payment under the composite rate portion of the blended payments

10 HCT/HGB Lab Results on Claims (as of 2013) As of 2013, is no longer valid amount in value code 48(HGB) or 49 (HCT) Report HCT/HGB for 98% of patients to receive credit CMS does not want to encourage unnecessary testing or unduly burden a facility. Can report HGB/HCT from another provider/facility and those labs are evaluated by an accredited laboratory (accredited by State agency or the College of American pathologists or other agencies) when not able to draw sample Example a transient patient Value Code 48/49 still needed on ESRD claims without ESAs

11 CMS Reiterations Drug Add-on adjustment is the same as 2012 CPT modifier AY usage Required Non ESRD-related ICD-9 diagnosis CMS will continue monitoring AY usage CMS may consider eliminating the AY modifier in future rulemaking Drugs used for ESRD Access Skin Infection treatment of any skin infection that is related to renal dialysis access management would be considered a renal dialysis service ESRD Facility cannot require ESRD beneficiaries not to use their Part D plan for their purchases 42 CFR prohibits providers from billing beneficiaries for services for which they are entitled to have payment made under Medicare.

12 2013 Final QIP Changes

13 2013 QIP Measurements Performance Year is 2011 Measurements Percentage of patients with HGB greater than 12 g/dl Percentage of patients with URR greater than 65% Retired HGB less than 10 g/dl This is consistent with the clinical practice guidelines and the labeling approved by the FDA for ESAs in June 2011 Facilities must have at least 11 patients eligible for each measure to receive a Total Performance Score.

14 HGB Greater than 12 g/dl 2013 QIP Exclusions Claims will be excluded from the measure calculation if the patient Is less than 18 years old as of the start date of the claim Is in the first 89 days of ESRD as of the start date of the claim Has reported HGB (or HCT / 3) less than 5g/dL or greater than 20 g/dl Is not treated with ESA according to the claim Has fewer than 4 months of eligible claims at the facility in measurement period

15 URR 2013 QIP Exclusion Claims will be excluded from the measure calculation if the patient Is less than 18 years old as of the start of the claim Has fewer than 7 treatments per month (G6 CPT modifier) Is in the first 182 days of ESRD as of the start date of claim Is on Home Hemodialysis or PD according to claim Has 4 or more sessions per week as a standard order Has fewer than 4 months of eligible claims at a facility in the measurement period

16 2013 QIP Scoring and Scale Range is 0 to 30 (30 is top score) Sliding Scale on Payment Reduction Total Performance Points Percentage of Payment Reduction 30 points 0% points 1.0% points 1.5 % 20 or fewer points 2.0%

17 2013 Total Performance Score Facility meets or exceeds performance standard for a measure: 10 points Facility does not meet performance standard for a measure: 2 points subtracted from 10 points for every 1% below the performance standard Total Performance Score = Sum of the two measurements X 1.5

18 2014 Final QIP Changes

19 2014 QIP Measurements Performance Year is now 2012 (was 2011) Improvement thresholds based on calendar year 2011 Clinical Measurements HGB greater than 12 g/dl URR greater than 65% Vascular Access Type (VAT) - NEW Reporting Measurements NHSN Dialysis Event Reporting - NEW ICH CAHPS Survey Reporting - NEW Mineral Metabolism Reporting - NEW

20 2014 QIP Vascular Access Type (VAT) % of hemodialysis patients using an AVF during last treatment of the month (higher % the better) % of hemodialysis patients using intravenous catheter during the last treatment of month and for at least 89 days. (lower % the better) A facility must have at least 11 cases to be scored on this measure. Each sub-measure receives a score Averaged to derive the VAT measure score Cases are aggregated across both sub-measures

21 2014 QIP Clinical Measures Exclusions The exclusions for HGB greater than 12 g/dl and URR of at least 65% are the same as 2013 Vascular Access Type (VAT) Claims are excluded from the AVF sub-measure if the patient Less than 18 years old as of the start date of claim Is on PD according to claim Has fewer than 4 months of eligible claims at the facility in performance period Claims are excluded from the catheter sub-measure if the patient Less than 18 years and 90 days old as of the start date of claim Is on PD according to claim Has fewer than 4 consecutive months of eligible claims at the facility in performance period

22 2014 Calculating the NHSN Dialysis Event Reporting QIP Measure To earn 10 points (max) a facility Enroll in NHSN and complete the required training during or prior to CY 2012 AND Report at least 3 consecutive months of dialysis event data collected during CY 2012 by 4/30/2013 To earn 5 points Enroll in NHSN and complete the required training during or prior to CY 2012 Facilities that do not enroll and receive training during or prior to CY 2012 will receive 0 points Facilities receive CMS Certification Number (CCN) after June 30, 2012 will only be scored if it successfully completes requirements to obtain 10 points

23 Calculating the ICH CAHPS Reporting QIP Measure To earn 10 points (max) Attest to successfully administering the ICH CAHPS survey during CY 2012 via CROWNWeb by 1/30/2013 If the ICH CAHPS measure does not apply to a facility, you must still complete an attestation via CROWNWeb stating that the measure is not applicable 0 points for eligible facilities that do not make this attestation

24 Calculating the Mineral Metabolism Reporting Measure To earn 10 points (max) Attest via CROWNWeb by 1/30/2013 to measuring serum calcium and serum phosphorus levels of all Medicare patients treated by that facility at least once per month throughout CY points are award to facilities that do not make this attestation

25 2014 QIP Scoring and Scale Range 0 to 100 (100 is the top score) Sliding Scale on Payment Reduction Total Performance Points Percentage of Payment Reduction points 0% points 0.5% points 1.0% points 1.5 % 25 or fewer points 2.0% Total Performance Points Composition 90% Clinical Measures 10% Reporting Measures

PY 2014 QIP Measures: Eligible claims by Modality From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2013 and 2014.

26 PY 2014 QIP Measures: Eligible claims by Modality From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2013 and CMS Special Open Door Forum, 19 February Web. 8 Aug <

27 2015 Proposed QIP Changes

28 2015 Proposed QIP Measurements Remember that these are proposed QIP measurements CMS has repeatedly requested feedback through the comment period Total number of QIP measurements since Three 2013 Two 2014 Six 2015 Proposed Eleven Why so many???

Six Domains of Quality Measurements Based on the National Quality Strategy From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year

29 Six Domains of Quality Measurements Based on the National Quality Strategy From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

30 2015 QIP Measurements Clinical Care Domain Anemia Management HGB greater than 12 g/dl Dialysis Adequacy Retiring URR and replacing with Kt/V Kt/V - NEW for QIP Adults hemodialysis patients (in-center and at home) Adult peritoneal dialysis patients Pediatric hemodialysis patients

31 2015 QIP Measurements Clinical Care Domain Vascular Access Management An AV fistula measurement A catheter measurement Mineral Metabolism Management Hypercalcemia - NEW Mineral Metabolism - Revised

32 2015 QIP Measurements Two other National Quality Strategy Domains Safety Management Safety Domain National Healthcare Safety Network Dialysis Event Reporting (NHSN) Revised Patient- and caregiver-centered experience Domain In-Center Hemodialysis Consumer Assessment of Healthcare Providers and System Survey (ICH CAHPS)

33 Proposed 2015 QIP Measurements Unchanged from Prior Years Percentage of patients with a mean HGB greater than 12 g/dl Percentage of patient-months on HD during last HD treatment of the month using AVF with two needles Percentage of patients-months on HD during the last HD treatment of month with a catheter continuously for 90 days or longer prior to the last HD session. ICH CAHPS Survey

34 2015 QIP spkt/v Adult Hemodialysis Measure % of hemodialysis patients-months with spkt/v greater than or equal to 1.2 Exclusions Patients younger than 18 years PD Patients Patients on dialysis for fewer than 90 days Patients scheduled dialyzing 4x or more per week Patients dialyzing 2x or fewer per week Patients with a spkt/v less than 0.5 or greater than 2.5 Patients treated at the facility less than 2x during the claim month Patients not on chronic dialysis (defined by completed 2728 or SIMS)

35 2015 QIP Kt/V Adult PD Measure % of hemodialysis patients-months with Kt/V greater than or equal to 1.7 (dialytic + residual) during 4- month study period Exclusions Patients younger than 18 years Hemodialysis patients Patients on dialysis for fewer than 90 days Patients with a Kt/V less than 0.5 or greater than 5.0 Patients not on chronic dialysis (defined by completed 2728 or SIMS)

36 2015 QIP spkt/v Pediatric Hemodialysis Measure % of hemodialysis patients-months with spkt/v greater than or equal to 1.2 Exclusions Patients 18 years or older PD Patients or home hemodialysis Patients on dialysis for fewer than 90 days Patients dialyzing 5x or more per week Patients dialyzing 2x or fewer per week Patients with a spkt/v less than 0.5 or greater than 2.5 Patients treated at the facility less than 2x during the claim month Patients not on chronic dialysis (defined by completed 2728 or SIMS)

37 2015 QIP - Hypercalcemia Clinical measure builds on Mineral Metabolism reporting measure in PY 2014 and PY 2015 Proportion of patient-months with 3-month rolling average of total uncorrected serum calcium greater than 10.2 mg/dl Uncorrected means not corrected for albumin Applies to all patients treated by the facility (not just Medicare patients) CROWNWeb Exclusions Patients younger than 18 years old Patients present at the facility for fewer than 30 days Patients on dialysis for fewer than 90 days Patients without a serum calcium value at the facility during the reporting month Patients not on chronic dialysis (defined by completed 2728 or SIMS) Patients with fewer than 3 eligible claims at the facility

38 Calculating the NHSN Dialysis Event Reporting Measure (Revised in 2015) To earn 10 points (max) a facility Meets the reporting requirements for 12 months in the performance period To earn 5 points Meets the reporting requirements for at least 6- consective months in the performance period To earn 0 points Reports less than 6-consective months

39 Calculating the Mineral Metabolism Reporting Measure (Revised in 2015) To earn 10 points (max) a facility Meets the reporting requirements for 12 months in the performance period To earn 5 points Meets the reporting requirements for at least 6- consective months in the performance period To earn 0 points Reports less than 6-consective months

PY 2015 Measures: Eligible claims by Modality From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2015.

40 PY 2015 Measures: Eligible claims by Modality From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

41 2015 Scoring and Scale Range 0 to 100 (100 is the top score) Sliding Scale on Payment Reduction (Estimated) Total Performance Points Percentage of Payment Reduction 52 or more points 0% points 0.5% points 1.0% points 1.5 % 21 or fewer points 2.0%

42 2015 Scoring and Scale Total Performance Points Composition 80% clinical scores HGB > 12 g/dl Kt/V Dialysis Adequacy Vascular Access Type Hypercalcmia 20% reporting scores Anemia Management NHSN Dialysis Event Mineral Metabolism ICH CAHPS Reporting

PY 2015 Scoring and Payment Reduction Methodology From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2015.

43 PY 2015 Scoring and Payment Reduction Methodology From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

44 Possible Future QIP Measurements Standard Mortality Ratio (SMR) Standard Hospitalization Ratio (SHR) Admission CMS will publish SHR by provider 30-day readmissions Population/community health Efficiency/cost of care Assessing health-related quality of life Access to care Transfusions From End-Stage Renal Disease Quality Incentive Program. CMS Special Open Door Forum, 19 July Web. 8 Aug <

45 Scheduled Changes in TIME When you receive TIME v7.2 Service Pack (SP) 15 Conversion between QIP score and QIP percentages for 2013 through ESRD PPS Bundle factors May be additional hot patch(es) to SP 15 depending upon the final CMS regulations. Tasks you need to do prior to 1/1/2013 Facility Maintenance Reimbursement Schedule Medicare Schedule

46 Facility Code Maintenance Wage Index, QIP & Low Volume

47 Reimbursement Schedule - Medicare Create New Entry. Also remember non-treatments reimbursements (especially the service that can be given for non- ESRD reasons)

48 Possible Additional Changes in TIME Expanded Crystal QIP Lab Results Report Monitoring to see if NHSN Dialysis Event Reporting will have an electronic format available

49 Questions??

50 Thank You

51 Additional Resources

52 Terms CPT Current Procedural Terminology CROWNWeb Consolidated Renal Operations in a Web-Enabled Network CY ESRD HD ICH CAHPS NHSN PPS PD PY QIP Calendar Year End-Stage Renal Disease Hemodialysis In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems National Healthcare Safety Network Prospective Payment Program Peritoneal Dialysis Payment Year Quality Incentive Program

53 Comparison of 2012, 2013 and 2014 QIPs From End-Stage Renal Disease Quality Incentive Program Review Your Facility s PY 2013 Performance Data., CMS Special Open Door Forum, 19 July Web. 8 Aug < >.

Comparison of 2014 and 2015 QIPs From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2015.

54 Comparison of 2014 and 2015 QIPs From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

PY 2015: Estimated Achievement Thresholds, Benchmarks and Performance Standards From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment

55 PY 2015: Estimated Achievement Thresholds, Benchmarks and Performance Standards From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

PY 2015: Estimated Achievement Thresholds, Benchmarks and Performance Standards (cont) From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment

56 PY 2015: Estimated Achievement Thresholds, Benchmarks and Performance Standards (cont) From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

ESRD QIP Timeline From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year 2015.

57 ESRD QIP Timeline From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

58 CMS Resources: Websites Medicare Improvements for Patients and Providers Act of 2008 (MIPPA): 110publ275/pdf/PLAW-110publ275.pdf CMS website for the ESRD QIP: (or Google CMS + ESRD ) ESRD Network Coordinating Center (NCC): Dialysis Facility Compare: Dialysis Facility Reports: From End-Stage Renal Disease Quality Incentive Program. CMS Special Open Door Forum, 19 July Web. 8 Aug <

59 CMS Resources: 2013 ESRD PPS and QIP 2013 Proposed ESRD PPS (CMS-1352-P): Payment/ESRDpayment/End-Stage-Renal-Disease-ESRD-Payment-Regulations-and- Notices-Items/CMS-1352-P.html 2013 and 2014 QIP Final Rule Presentation: Stage-Renal-Disease/ESRDQualityImproveInit/Downloads/13-14QIPODF pdf 2015 Proposed QIP Presentation: Renal-Disease/ESRDQualityImproveInit/Downloads/PY15NPRMODF pdf ESRD PPS Overview of 2011 Claim Based Monitoring: Payment/ESRDpayment/Downloads/ESRD_PPS_Overview_of_2011_Claims_Based _Monitoring.zip From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

60 CMS Resources: Clinical Measurements Anemia Management: AnemiaManagement-HGB-2015-NPRM.pdf Kt/V Dialysis Adequacy measure topic Adult Hemodialysis: HemodialysisAdequacy-ktv-2015-NPRM.pdf Adult Peritoneal Dialysis: Pediatric Dialysis: PediatricHemodialysisAdequacy-ktv-2015-NPRM.pdf Vascular Access Type measure topic AVF: NPRM.pdf Catheter: VascularAccess-Catheter NPRM.pdf Hypercalcemia: Hypercalcemia-2015-NPRM.pdf From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

61 CMS Resources: Reporting Measures Anemia Management: ICH CAHPS: Mineral Metabolism: NHSN Dialysis Event Reporting: From End-Stage Renal Disease Quality Incentive Program Notice of Proposed Rulemaking: Payment Year CMS Special Open Door Forum, 19 July Web. 8 Aug <

Quarterly Dialysis Facility Compare - Preview for April 2018 Report DFC Dialysis Facility State: XX Network: 99 CCN: SAMPLE

Quarterly Dialysis Facility Compare -- Preview for April 2018 Report This Quarterly DFC Preview Report includes data specific to CCN(s): 999999 Purpose of the Report This report provides you with advance