Implementing Successful Value-based Payment: Alternative Payment . - CAQH
vePayment Modelswith CMMIThursday, January 11, 20182:00 – 3:00 pm ET 2018 CAQH, All Rights Reserved.
LogisticsPresentation Slides & How to Participate in Today’s SessionDownload the presentation slides at www.caqh.org/core/events. Click on the listing for today’s event, then scroll to the bottom to find theResources section for a PDF version of the presentation slides. Also, a copy of the slides and the webinar recording will be emailed to allattendees and registrants in the next 1-2 business days.Questions can be submitted at any time with the Questions panelon the GoToWebinar dashboard. 2018 CAQH, All Rights Reserved.2
Session Outline Overview of CAQH CORE Role in Value-based Payments. Featured Presentation: CMMI's Comprehensive Primary Care Plus. Model Overview. Practice Transformation. Payment and Data Redesign. Audience Q&A. 2018 CAQH, All Rights Reserved.3
CAQH CORE and CMMI WebinarThis webinar is the second in an ongoing educational seriesfrom CAQH CORE to address operational challengesinherent in the transition to value-based payments.We would like to thank our speakers:Dr. Laura SessumsDirector of the Division of Advanced PrimaryCare, CMMIErin WeberDirector, CAQH CORE 2018 CAQH, All Rights Reserved.4
CAQH CORE Role in Value-basedPaymentsErin WeberCAQH CORE Director 2018 CAQH, All Rights Reserved.5
CAQH CORE Mission and VisionMISSIONVISIONDESIGNATIONBOARDDrive the creation and adoption of healthcareoperating rules that support standards,accelerate interoperability and alignadministrative and clinical activities amongproviders, payers and consumers.Research &Develop RulesAn industry-wide facilitator of a trusted,simple and sustainable healthcare dataexchange that evolves and aligns withmarket needs.Named by Secretary of HHS to benational author for three sets ofoperating rules mandated by Section1104 of the Affordable Care Act.Track Progress,ROI & ReportMulti-stakeholder. Voting members are HIPAAcovered entities, some of which are appointedby associations such as AHA, AMA, MGMA.Advisors are non-HIPAA covered, e.g. SDOs. 2018 CAQH, All Rights Reserved.Design Testing& OfferCertificationMaintain &UpdatePromoteAdoption6Integrated Model forWorking with IndustryBuild Awareness& EducateProvideTechnicalAssistance
Streamlining Value-based Payments OperationsCAQH CORE is a Proven Agent of ChangeChange AgentConsiderable expertise, experienceand resources to supportdevelopment of a soundoperational system for Valuebased Payments (VBP)*.Proven SuccessSignificant improvements in feefor-service operations, reducingcost and improving care delivery andadministrative coordination.Industry CollaborationExpertise developing operating rulesfor the administrative and financialareas where providers and healthplans must work together -- ability toharmonize practices betweenproviders and health plans, withmore than 130 participatingorganizations.By collaborating now and applying lessons learned through successes in the fee-for-service space, CAQHCORE hopes to energize an effort ensuring the historic volume-to-value shift continues to beunimpeded by administrative hassles.*The term “value-based payment” is used, recognizing that other terms may also be appropriate, such as incentive payment models, care delivery models, etc. 2018 CAQH, All Rights Reserved.7
From Fee-for-Service to Value-based PaymentsOperational Capabilities Essential to Support Shift from Volume to ValueCAQH CORE recognizes the importance of emerging value-based payment (VBP) models inachieving improved healthcare quality and cost:providers currentlyengaged in VBP.Expected that more thanhalf of healthcarepayments will be valuebased by 2020.VBP models alreadyaccruing cost-savingswith equal or bettercare results.(Modern Healthcare, 2017)(Forbes, 2017)(American Hospital Association, 2016)30%-50%Transition to VBP not without challenges – improvement in operational capabilities needed to ensure success. Proprietary systems and processes implementing VBP have introduced operational variations, unintentionally settingup a scenario ripe for repeating prior mistakes. The volume-to-value transformation may slow if providers encounter barriers that make participation burdensome –need efficient, uniform operational system as support. Important to collaborate now within the industry to standardize and coordinate operations early, before proprietarysystems and processes become entrenched. 2018 CAQH, All Rights Reserved.8
CAQH CORE Efforts on Value-based PaymentsOpportunity AreasCAQH CORE will release VBP report outlining results from its primary and secondary research includingoutlining problem space, opportunity areas and recommended actions. 2018 CAQH, All Rights Reserved.9
Challenges: Areas Impacting Value-based PaymentsData Standardization: Missing or inaccurate provider and patient data. Lack of specificity for some medical code sets (LOINC & SNOMED). Inconsistent use of common terms not currently standardized.Interoperability: Technical interoperability with use of different information systems can affect data accuracy and validity. Lack of a process interoperability for how information is exchanged and how actions are interpreted byother stakeholders.Patient Risk Stratification & Risk Assessment: Data needed can be costly to collect and analyze due to differing and proprietary models used by payersand providers. Model variation leads to provider confusion and inhibits their ability to provide timely, cost-effective care.Quality Measurement: Overabundance of quality measures burden provider's ability to complete reporting requirements for VBPinitiatives. 2018 CAQH, All Rights Reserved.10
TimelineVBP Activities to Date and Beyond 2018 CAQH, All Rights Reserved.11
Polling Question #1Is your organization actively working on value-based payment models/strategies? Yes – we are actively implementing value-based models. Yes – we are actively designing models for implementation. No. Unsure. 2018 CAQH, All Rights Reserved.12
Comprehensive Primary Care PlusTransforming Primary Care in AmericaCouncil for Affordable Quality Healthcare, Inc.January 11, 2018Laura L. Sessums, JD, MD, FACPComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation13
Agenda1CPC Model Overview Multi-payer partnership Geographic regions Key statistics2Practice Transformation Activities and Supports Five care delivery functions drive practice transformation Enhanced health IT supports care delivery redesign Learning support for practices and payers3Payment and Data Redesign Medicare payment innovations and quality performance Centralized data feedback Alternative Payment Models (APMs) and QPPComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation14
Advancing Care Delivery and PaymentFee-for-ServicePrimary Care Focus on volumeHigh-cost servicesIn-person encountersFragmented careProvider burnoutPayer segregationLittle attention to socialdeterminants of healthPractice Transformation Actionable milestones to deliver high quality,whole-person, patient-centered care Effective use of health informationtechnology (HIT) and data analytics Practice learning networksPayment Redesign Non-visit based care management fees Regional shared savings opportunityComprehensive Primary Care PlusComprehensivePrimary Care Focus on efficient, highquality care High-value utilization Population-based caredelivery Engaged patients,caregivers, and families Multi-payer support Coordination across themedical neighborhood andcommunity servicesCenter for Medicare & Medicaid Innovation15
Multi-Payer PartnershipEssential for Primary Care ReformMedicareFFSMulti-payer engagement is anessential component of CPC .Support from any one payercovers only a portion of apractice’s population.True comprehensive primarycare possible only with thesupport of multiple payers.In CPC , CMS partners withpayers that share Medicare’scommitment to strengtheningprimary care in America.Comprehensive Primary Care PlusMedicaid/CHIPmanagedcare plansMedicaid/CHIP stateagenciesCPC r for Medicare & Medicaid Innovation16
CPC Now Offered in 18 RegionsMTGreater Buffalo(NY)NDORRhode IslandMINECOOKOHGreaterKansasCityARNorth Hudson/Capital District (NY)New JerseyTNGreater Philadelphia (PA)Northern KY (part of OH region)LAHawaii 2017 Cohort 2018 Cohort Sub-state region comprising contiguous countiesComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation17
Comprehensive Primary Care PlusAmerica’s Largest-Ever Initiative to Transform Primary Care2017 COHORT5214 2,800YearsTracksRegionsPractice Sites 13,000 1.76 million 50 55CliniciansMedicare BeneficiariesPayer PartnersHIT Vendor Partners2018 COHORT549YearsNew RegionsNew PayersNew PracticesFrom 2018-2022Selected based on payercommitment to partnershipIncluding 7 supportingRound 1 regionsBased on eligibilityfor Track 1 or Track 2Comprehensive Primary Care Plus160 Center for Medicare & Medicaid Innovation18
Participation in Both Program TracksTrack1Track2Over 1,400 primarycare practices.Practices will build the capabilities todeliver comprehensive primary care.Over 1,500 primarycare practices.Practices will increase the comprehensivenessof care through enhanced health IT, improve care19of patients with complex needs, and inventoryresources and supports to meet patients’psychosocial needs.Comprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation19
Five Functions Guide CPC Care Delivery TransformationAccess andContinuityCareManagementPatient and CaregiverEngagementComprehensivenessand CoordinationPlanned Care andPopulation HealthOnline Resources: Care Delivery Transformation Brief, Video, and Practice RequirementsComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation20
CPC Practices Enhance Care Delivery Capabilitieseach Program YearRequirements forTrack 1Requirements forTrack 2EmpanelmentAccess andContinuityAlternative to traditional officevisits, e.g., e-visits, phone visits,group visits, home visits, and/oralternate location visits.24/7 patient accessAssigned care teamsMeasure continuity of careCareManagementRisk stratified patient populationTwo-step risk stratification processfor all empanelled patientsShort-term and targeted, proactive,relationship-based care managementTwo-step risk stratificationprocess for all empaneledpatientsCare plans for high-riskchronic disease patientsED visit and hospital follow-upTrack 2 capabilities are inclusive of and build upon Track 1 requirementsProgram Year capabilities build upon prior Program Year requirementsComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation2121
CPC Practices Enhance Care Delivery Capabilitieseach Program YearRequirements forRequirements forTrack 1Track 2Identification of high volume/costspecialistsComprehensiveness andCoordinationImproved timeliness of notificationand information transfer from EDsand hospitalsCollaborative care agreementsPatient andCaregiverEngagementPlanned Care andPopulation HealthCollaborative care agreementsComprehensive Medication ManagementPsychosocial needs assessment andinventory of resources and supportsAddress common psychosocial needsBehavioral health integrationBehavioral health integrationDevelopment of practice capabilities forpatient subpopulation with complex needsAt least annual Patient and FamilyAdvisory Council (PFAC)At least biannual PFACAt least biannual PFACAt least quarterly PFAC, and integraterecommendations into careAssessment of practice capabilitiesto support patient self-managementPatient self-management support forat least three high-risk conditionAdvance care planningAt least quarterly review of payerutilization reports and practice eCQMdata to inform improvement strategyAt least weekly care team review ofall population health dataComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation22
CPC Health IT RequirementsCertified Health IT is Required for Tracks 1 and 2Requirements forTrack 1Requirements forTrack 2Maintain/Adopt 2014 or 2015 EditionCertified EHR Technology byJanuary 1, 2017. Maintain/adopt2015 CEHRT by January 1, 2019(By 2019) Adopt technology certifiedto the 2015 Edition “Care Plan”criterion.eCQM reporting – adopt 2014 or2015 Edition certified health IT for thec(1)-c(3) functions – capture; importand calculate; and report eCQMs.(By 2019) Adopt technology certifiedto the 2015 Edition “Social,Behavioral, and PsychologicalData” criterion”Adopt technology which allows thefiltering of data by practice site andTIN/NPI by January 1, 2017. Adopttechnology meeting the 2015 Edition c(4)function (filter) by December 31, 2018Track 2 capabilities are inclusive of and build upon Track 1 requirements.Comprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation23
Required Health IT Functionalities inCPC Track 2Health IT vendor partners committed to supporting Track 2 Practices in developingand implementing these advanced functionalities across the five years of CPC .Now AvailableComing in 2019-2021Risk stratify the practice sitepatient population; identify and flagpatients with complex needsScreen for social and communitysupport needs and link the identifiedneed(s) to practice identified resourcesEmpanel patients to thepractice site care teamEstablish patient focused careplans to guide care managementProduce and display eCQMresults at the practice level tosupport continuous feedbackDocument and track patientreported outcomesComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation24
Opportunities for StakeholderLearning, Collaboration, and SupportCPC Practice PortalOnline tool for reporting,feedback, and assessment onpractice progress.Learning CommunitiesNational webinars and annualNational Stakeholder Meeting Cross-region collaboration.Virtual and in-person regionallearning sessionsWeb-based platform for CPC stakeholdersto share ideas, resources, and strategies forpractice transformation.Comprehensive Primary Care Plus Engagement with CPC stakeholders. Outreach and support fromregional learning faculty.Center for Medicare & Medicaid Innovation25
Opportunities for Practice and Payer EngagementThe following meetings are available to interested payer partners:Regional Payer TableNational Payer TableRegional PayerMeetings, asdetermined by payersCMS-Led WebinarsLAN PAC VirtualMeetingsAnnual LANSummitMilbank Multi-StateCollaborative MeetingsPayer-Specific EventsCPC NationalLearning CommunitiesPractice-FocusedEventsComprehensive Primary Care PlusNational LearningWebinarsCPC RegionalLearning CommunitiesRegional LearningEventsPlanning QuarterlyLearning Events (in2018)Quarterly Payer/PracticeLeadership Meetings (in2018)Practice Action Groups &Affinity Groups (in 2018)Data AggregationCoordination with CMSData Feedback Contractor(Deloitte)Center for Medicare & Medicaid Innovation26
Three Payment Innovations Support CPC PracticeTransformationCare Management Fee(PBPM)Performance-BasedIncentive Payment(PBPM)Payment StructureRedesignObjectiveSupport augmented staffingand training for deliveringcomprehensive primary careReward practiceperformance on utilizationand quality of careReduce dependence on visitbased fee-for-service to offerflexibility in care settingTrack 1 15 average(ranges from 6 to 30) 2.50 opportunityN/A(Medicare FFS) 4.00 opportunityHybrid Payment:a combination ofupfront “ComprehensivePrimary Care Payment” andreduced FFS claimsTrack 2 28 average(ranges from 9 to 100)CPC practices also in the Medicare Shared Savings Program participate in their ACO’sshared savings/loss arrangement INSTEAD of receiving CPC incentive payments.Comprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation27
Attribution Methodology*PracticeCPC Practitionercomposition changes must be updated for CMS’ recordsLook BackReview practitionerson your roster*Add/Drop TIN-NPIExamine universe ofclaims from look backperiodComprehensive Primary Care PlusBeneficiaryVisitsIdentify beneficiarieswho received visitsand codes fromCPC practitionersAssignbeneficiary topracticeApply plurality andrecency rules toassign beneficiariesto practiceOverlapsCheckEnsure beneficiariesare only in one sharedsavings-like program,except CPC practicesin SSP ACOsCenter for Medicare & Medicaid Innovation28
Care Management FeeCMS uses CMS-HCC scores: Hierarchical Condition CategoriesTrack 1: Four Risk Tiers 6 8 16 9 11 191st risk quartile2nd risk quartile3rd risk quartile 30Track 2: Five Risk Tiers 33HCC Risk Scores0%25%50%4th risk quartile75%90% 100%Complex Tier: 100Top 10% of HCC ordementia diagnosisComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation29
Performance-Based Incentive PaymentBased on performance on CAHPS, eCQMs, and Utilization metricsComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation30
Track 2 Hybrid PaymentDesigned to Promote Flexibility in Care Delivery and PopulationHealth Beyond Office VisitsTraditional practice paid onlythrough FFS; must see patients inoffice to receive reimbursementCPC Track 2 practice paid roughly half of FFS paymentsupfront in “Comprehensive Primary Care Payment” (CPCP) togive clinicians more flexibility in how/where they deliver careCPCPReducedFFSComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation31
CPC Data Feedback ApproachAttribution/Payment Data Quarterly list of Medicare FFSbeneficiaries attributed, by risk tier Quarterly financial supportamountsQuality Data Performance on Electronic ClinicalQuality Measures and CAHPSsurveys, compared to other practicesData SharingLeversCost and Utilization Data Expenditures: professional services,inpatient, outpatient, SNFs, etc. Utilization: inpatient, 30-dayreadmission, ED utilizationComprehensive Primary Care PlusMulti-Payer Aggregation Aligned report with multi-payer data Allows clinicians to view entire patientpopulation Reduces burden; enhances carecoordination and population healthCenter for Medicare & Medicaid Innovation32
Data Aggregation FlowPayerClaimsDataReportingStandardizedData SetDataAggregationprovides comparativemeasurement acrosssettingsPracticeTransformationIncorporating multi-payerinformation into healthcareoperations for continuousimprovementAnalytics makingthe data readable anduseableCompiling andstandardizing data fromdifferent sourcesComprehensive Primary Care PlusProvidersCenter for Medicare & Medicaid Innovation33
Practice Performance & Demographics (DummyData)Comprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation34
CPC Payment Under the MedicareQuality Payment ProgramCPC Practitioners Receive MIPS Special Scoring or ExemptionMerit-based Incentive Payment System(MIPS) Eligible Clinician in aMIPS APMQualifying APM Participant (QP) in anORAdvanced APMReport only one MIPS categoryExempt from MIPS reportingCPC Payment to MIPS ECsCPC Payment to QPsCMS will adjust your physician fee schedule(PFS) payments during the payment yearbased on your MIPS final score.CMS will make a lump sum payment that isequal to 5% of the payments for your PartB professional services.CPC PaymentsCPC Payments Physician Fee Schedule MIPS adjustmentPhysician Fee Schedule 5% lump sum bonusComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation35
Magnitude of MIPS Payment AdjustmentsChanges Over TimeMIPS EligibleCliniciansQualifying APMParticipantsIn 2019, QP status based on 2017 performance;5% lump sum bonus based on 2018 servicesIn 2019, MIPS payment adjustmentbased on 2017 performance0%0%20172018 /4% 5%2019 /5% 5% /7% 5%20202021Higher maximumopportunity in MIPSCPC participants in MIPS receive a special“APM Scoring Standard” for their MIPS adjustmentsComprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation36
For More Information on CPC omprehensive Primary Care PlusCenter for Medicare & Medicaid Innovation3737
Polling Question #2Which webinar topic is of most interest/relevance to you? (Select all the apply.) Overview and trends in VBP federal and industry initiatives. Interoperability. Patient Risk Stratification. Provider/Patient Attribution. Quality Measurement. 2018 CAQH, All Rights Reserved.38
Audience Q&APlease submit your questionsEnter your question into the “Questions”pane in the lower right hand corner of yourscreen.You can also submit questions at any timeto CORE@caqh.orgDownload a copy of today’s presentation slides at caqh.org/core/events Navigate to the Resources section for today’s event to find a PDF version of today’s presentation slides. Also, a copy of the slides and the webinar recording will be emailed to all attendees and registrants in thenext 1-2 business days. 2018 CAQH, All Rights Reserved.39
Upcoming CAQH CORE Education SessionsUse and Adoption of Attachments in Healthcare Administration, Part IV: ClinicalDocument Architecture (CDA) BasicsTHURSDAY, JANUARY 18TH, 2018 – 2 PM ETCAQH CORE Town Hall National WebinarTUESDAY, FEBRUARY 6TH, 2018 – 2 PM ETTo register for these, and all CAQH CORE events, please go to www.caqh.org/core/events 2018 CAQH, All Rights Reserved.40
Thank you for joining us!@CAQHWebsite: www.CAQH.org/COREEmail: CORE@CAQH.orgThe CAQH CORE MissionDrive the creation and adoption of healthcare operating rules that support standards,accelerate interoperability and align administrative and clinical activities amongproviders, payers and consumers. 2018 CAQH, All Rights Reserved.41
chronic disease patients Risk stratified patient population Two-step risk stratification process for all empanelled patients Alternative to traditional office visits, e.g., e-visits, phone visits, group visits, home visits, and/or alternate location visits. Empanelment Two-step risk stratification process for all empaneled patients
4 payment options available to sars clients 5 4.1 payment option 1 - using efiling to make your payment 5 4.2 payment option 2 - payment at a sars branch 7 4.3 payment option 3 - using the internet to make electronic payment 9 4.4 payment option 4 - bank payments (at one of the relevant banking institutions) 10 4.5 foreign payments 11
The main features in e-payment protocol are less charges of payment amount and high occurrence of transactions on the e-commerce system. 2.1Secure E-payment Protocol An e-payment process is a sequence of actions that involves a business task. There are mainly two kinds of payment transactions: i) Atomic payment transaction-single payment
6) payment instrument means any personalised device and/or a set of procedures agreed between the payment service user and the payment service provider and used by the payment service user in order to issue a payment order; 7) payment service user means a natural or legal person that uses or was using a payment service in the capacity of a payer
PayU Payment Gateway Solution V0.1, 02 February 2022 confidential, limit distribution, controlled Page 6 of 19 If payment is successful, the message Your transaction was successful displays as shown above. This system will automatically navigate back to the Member Portal. The Payment Successful message is displayed at the top of the screen. The Payment reference
date will need be stated on the payment claim itself. A payer has two options when it receives a Payment Claim: (1) make payment in full by the due date; or (2) use a Payment Schedule to dispute the amount claimed and pay a lesser amount (possibly 0). The Payment Schedule must be served a
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Payment Express. A token is provided that allows you to create a new payment using those saved card details. If there are saved tokens for a booking, you will see them listed when you open the payment page: To create a payment from a token, click the "reate Payment from Token" button, enter the payment amount and click continue:
The State of FQHC Value-Based Payment Reform: Lessons from NASHP's Value-Based Payment Reform Academy . Health First Colorado FQHC Payment Reform, Shane Mofford, Director of Rates and Payment Reform, Colorado Department of Health Care Policy and Financing. FUHN's Journey: Minnesota DHS's Integrated Health Partnership, Deanna Mills,
