Asthma And COPD Episodes - New York State Department Of Health

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Asthma and COPD episodesClinical Advisory Group Meeting 1Meeting Date: 8/26Source: Fee-for-Service and Managed Care encounter records forPulmonary Episode Patients in CY2012-2013. Source: HCI32015

August 26ContentIntroductions &Tentative Meeting Schedule and AgendaPart IA. Clinical Advisory Group Roles and ResponsibilitiesB. Introduction to Value Based PaymentC. Contracting Chronic Care: the Different OptionsD. HCI3 - Understanding the HCI3 Grouper and Development of Care EpisodesPart IIA. Impressions of Data Available for Value-Based Contracting2

August 26Introductions3

August 26Tentative Meeting Schedule & AgendaDepending on the number of issues addressed during each meeting, the meeting agenda for each CAG willlikely consist of the following:Meeting 1 Introduction to Value Based Payment Clinical Advisory Group- Roles and Responsibilities Understanding the Approach: HCI3 Overview Pulmonary Episodes – Definition Pulmonary Episodes – Impressions of Data Available for Value Based ContractingMeeting 2 Pulmonary Episodes Definition Recap Pulmonary Episodes Outcome Measures - IMeeting 3 Pulmonary Episode Outcome Measures - II4

August 26Part IA. Clinical Advisory Group (CAG) Roles & ResponsibilitiesRoles and Responsibilities Overview5

6August 26Clinical Advisory Group CompositionComprehensive Stakeholder EngagementComposition of the CAG includes: Comprehensive stakeholder engagement Clinical experience and knowledge focusedhas been a key component to theon the specific care or condition beingdevelopment of the Value Based Paymentdiscussed (pulmonary)Roadmap. Industry knowledge and experience We will continue engaging stakeholders as Geographic diversitywe develop and define opportunities for Total care spectrum as it relates to thevalue based payment arrangements.specific care or condition being discussed

August 26CAG Objectives Understand the State’s visions for theRoadmap to Value Based Payment The CAGs will be working with nationalstandard bundles and are not asked totailor definitions at this point, but focus on Understand the HCI3 grouper andoutcome measures and NYSunderlying logic of the bundlesimplementation details. Working Review clinical bundles that are relevant to experience with bundles can lead to newNYS Medicaidinsights and definition enhancements aswith any reimbursement methodology. Make recommendations to the State on: outcome measures Definitions are standard, but financial data and other support required forarrangements between plans andproviders to be successfulproviders around the bundles are not set other implementation details related toby the State.each bundle7

8August 26Pulmonary episodes represent 1.16B over two yearsCost Composition of Pulmonary EpisodesVolume Makeup of Pulmonary EpisodesTotal Pulmonary Costs: 1.16B in two years (2012-2013)Total Pulmonary Episodes: 564K in two years (2012-2013)COPD, 276M, 24%COPD,120K, 21%ASTHMA, 879M, 76%Costs Included: Fee-for-service and MCO payments (paid encounters); Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.Source: 01/01/2012 – 12/31/2013 Medicaid claims. Dual population not included. 100k beneficiaries (2%) have been excluded due to data quality issuesASTHMA,443K, 79%

August 26Part IB. Introduction to Value Based PaymentBrief background and context9

10August 26NYS Medicaid in 2010: the Crisis 10% growth rate had becomeunsustainable, while quality outcomes werelagging Costs per recipient were double thenational average NY ranked 50th in country for avoidablehospital use 21st for overall Health System Quality2009 Commonwealth State Scorecardon Health System PerformanceCARE MEASURENATIONALRANKINGAvoidable Hospital Use and Cost50th Percent home health patientswith a hospital admission49th Percent nursing home residentswith a hospital admission34th Hospital admissions for pediatric 35thasthma Medicare ambulatory sensitivecondition admissions40th Medicare hospital length of stay 50th

11August 26Medicaid Redesign Initiatives Have Successfully Brought BackMedicaid Spending per Beneficiary to below 2003 LevelsSince 2011, total Medicaid spendinghas stabilized while number ofbeneficiaries has grown 12%Medicaid spending per-beneficiaryhas continued to decrease

12August 26Delivery Reform and Payment Reform: Two Sides of the SameCoin A thorough transformation of the deliverysystem – DSRIP - can only become andremain successful when the payment systemis transformed as well Many of NYS system’s problems(fragmentation, high re-admission rates) arerooted in how the State pays for service FFS pays for inputs rather than outcome;an avoidable readmission is rewardedmore than a successful transition tointegrated home care Current payment systems do notadequately incentivize prevention,coordination, or integrationFinancial and regulatory incentivesdrive a delivery system which realizes cost efficiency and quality outcomes:value

August 26Payment Reform: Moving Towards Value Based Payments A Five-Year Roadmap outlining NYS’ plan for Medicaid Payment Reform wasrequired by the MRT Waiver By DSRIP Year 5 (2019), all Managed Care Organizations must employ non feefor-service payment systems that reward value over volume for at least 80-90%of their provider payments (outlined in the Special Terms and Conditions of thewaiver) Core Stakeholders (providers, MCOs, unions, patient organizations) have activelycollaborated in the creation of the Roadmap13

14August 26Learning from Earlier Attempts: VBP as the Path to a StrongerSystemVBP arrangements are not intended primarily to save money for the State, but to allowproviders to increase their margins by realizing valueGoal – Reward Value not Volume

15August 26The VBP Roadmap starts from DSRIP Vision on How anIntegrated Delivery System should FunctionMaternity Care (including first month of baby) Integrated Physical &Behavioral Primary CareIncludes social servicesinterventions and ;community-basedprevention activitiesPopulation Health focus on overallOutcomes and total Costs of CareEpisodicChronic care(Diabetes, CHF, Hypertension, Asthma, Depression, Bipolar )Chronic Kidney DiseaseHemophilia AIDS/HIVMultimorbid disabled / frail elderly (MLTC/FIDA population)Severe BH/SUD conditions (HARP population)Developmentally Disabled population ContinuousSub-population focus on Outcomes andCosts within sub-population/episode

16August 26The Path Towards Payment Reform: A Menu of OptionsThere is not one path towards Value Based Payments. Rather, there will be a variety of optionsthat MCOs and PPSs/providers can jointly choose from.PPSs and MCOs can opt for different shared savings/risk arrangements (often building on alreadyexisting MCO/provider initiatives): For the total care for the total attributed population of the PPS (or part thereof) – ACO modelPer integrated service for specific condition (acute or chronic bundle): maternity care; diabetes careFor integrated Advanced Primary Care (APC)For the total care for a subpopulation: HIV/AIDS care; care for patients with severe behavioral health needs andcomorbiditiesMCOs and PPSs can make shared savingsarrangements for the latter types ofservices between MCOs and groups ofproviders within the PPS rather thanbetween MCO and PPS.

17August 26MCOs and PPSs can choose different levels of Value BasedPaymentsIn addition to choosing what integrated services to focus on, the MCOs and PPSs can choosedifferent levels of Value Based Payments:Level 0 VBPLevel 1 VBPLevel 2 VBPLevel 3 VBP(only feasible after experience with Level2; requires mature PPS)FFS with bonus and/orwithhold based on qualityscoresFFS with upside-only shared savingsavailable when outcome scores aresufficient(For PCMH/APC, FFS may becomplemented with PMPM subsidy)FFS with risk sharing(upside available whenoutcome scores aresufficient)Prospective capitation PMPM or Bundle(with outcome-based component) Goal of 80-90% of total MCO-provider payments (in terms of total dollars) to be captured inLevel 1 VBPs at end of DY5 35% of total managed care payments (full capitation plans only) tied to Level 2 or higher. For Level2 (risk-bearing VBP arrangements), the State excludes partial capitation plans such as MLTC plansfrom this minimum target.

18August 26Value Information per VBP Arrangement(using price-standardized data)Providers and MCOs will receive Cost and Quality performance overviews per VBParrangement (whether these arrangements are contractedor not) Including Target Budgets and actual costs (both coststandardized, and, for their own beneficiaries, real-priced)Initially, PDF reports will be used, but providers andMCOs will get access to web-based analytical tools todynamically interact with these data Including drill downs by geography and provider Including drill down possibilities to individual patients (forown beneficiaries)

August 26Part IC. Contracting Chronic Care: the Different Options19

August 26The Context: Strong Push to Strengthen Primary Care in NYS Strengthening Primary Care has long been a central piece of DOH policy DSRIP includes significant focus on Integrated Behavioral and Physical Care withinthe Primary Care context New York State Health Innovation Plan centers on the concept of AdvancedPrimary Care20

August 26The Context: Advanced Primary Care in NYSThe APC model will go beyond new structures and capabilities to specify and measureprocesses and outcomes associated with more integrated care, including prevention,effective management of chronic disease, integration with behavioral health, andcoordination among the full range of providers working together to meet consumer needs.[.T]his is essential in moving away from a reactive health care system that patients largelyhave to navigate on their own, to a truly proactive system, in which patients are helped toactively manage and improve their health.New York State Health Innovation Plan21

22August 26APC Stages of TransformationAPC Model Closely alignedto DSRIP milestonesTierPre-APCStandard APCPremium APCDescription Largely reactive approach to patientencounters of care Capabilities in place to moreproactively manage a population ofpatients Processes in place to clinically integrateprimary, behavioral, acute, post-acutecare1 Certified EHR, Meaningful Use Stage 133, HIE interoperability Enhanced capabilities, aligned withexpanded NCQA Level 32, or equivalentCapacilitiesrequired toenter tier Limited pre-requisites Willingness to exchange targetedclinical data Certified EHR Full medical home capabilities alignedwith NCQA level 1-3, or equivalentValidationNone Required to maintain care coordination fees 12 months To couple with practice transformation supportLimited or none Care planning for 5-15% highest-riskpatients Track and follow up on ADT, otherscalable data streams Facilitate referrals to high-valueproviders Plus, functional care agreements inmedical neighborhood Plus, community facing carecoordination Shared savings or capitation Care coordination fees Transformation support Shared savings or capitationCarecoordinationskillsPayment model FFS P4Pmix Potential EHR supportMetrics andreporting Standard statewide scorecard of core measures Consolidated reporting across payers, leveraging APD, portal1Vision, LTC, home aids, rehabilitative & daycare are excluded from all advanced primary care modelsEstablishes, additional must pass NCQA requirements, that are not already mandatory in existing NCQA3Once available2

23August 26Vision on Chronic Care Contracting in NYS VBPType of Population / ConditionPopulation / ConditionType of ContractingFor specific subpopulations: intensive andinterdependent chronic care needs, bestcoordinated by specialized provider HIV/AIDSHARPMLTCTotal Care for Subpopulation (capitation); i.e., acondition-specific ACO modelFor highly specialized chronic conditions:intensive chronic care needs, best providedby specialized providers Chronic Kidney DiseaseHemophiliaBundleFor more common chronic conditions:integrated approach is part and parcel of APCvision AsthmaCOPDChronic DepressionBipolar DisorderSubstance Use DisorderCoronary Artery DiseaseHypertensionCHFArrhythmia / Heart BlockGastro-Esophageal Reflux DiseaseThe default is that the individual chronic bundlesare contracted together by integrated careproviders (guideline)

24August 26Advanced Primary CareDefault is that these arecontracted together Integrated Physical &Behavioral Primary Care but not all bundlesneed to be included and some bundlesmay be contracted byother providers‘Chronic Bundle’AsthmaCOPDIncludes social servicesChronic DepressionFinally,a TotalinterventionsandCare for the Total Population (ACO) model includes the careBipolar Disordercommunity-based included in these chronic care bundlesSubstance Use Disorderprevention activitiesCoronary Artery DiseaseHypertensionCHFArrhythmia / Heart BlockGastro-Esophageal Reflux Disease

August 26Part ID. HCI3 Understanding the Grouper & Development of Care Episodes25

August 26Why HCI3? One of two nationally used bundled payment programs Specifically built for use in value based payment Not-for-profit and independent Open source Clinically validated National standard which evolves based on new guidelines as well as lessons learned26

27August 26Evidence Informed Case Rates (ECRs)Evidence Informed Case Rates (ECRs) are the HCI3 episodedefinitions ECRs are patient centered, time-limited, episodes of treatment Include all covered services related to the specific condition E.g.: surgery, procedures, management, ancillary, lab,pharmacy servicesAll patient servicesrelated to a singlecondition Distinguish between “typical” services from “potentiallyavoidable” complications Are based on clinical logic: Clinically vetted and developedbased on evidence-informed practice guidelines or expertopinionsSource: HCI3 Presentation: mSum of services (based onencounter data the Statereceives from MCOs).

28August 26Clinical LogicA Pulmonary Episode (Asthma as an Example)AsthmaLook BackInitial doctor visit,during which adiagnosis of asthma isgiven.Doctor visit for abroken bone (e.g. asports injury) unrelatedto asthmaER Visits and inpatientadmissions related toasthma episodeconditionsPrescription medicineto treat asthmacondition.Inpatient admissioncaused by acuteexacerbation.

29August 26Episode Component: Triggers A trigger signals the opening of an episode, e.g: Inpatient Facility Claim Outpatient Facility Claim Professional Claim More than one trigger can be used for an episode Often a confirming claim is used to reduce falsepositives Trigger codes are unique to each episode—nooverlapsTriggers Asthma and COPD:Relevant IP claim asthmaASTHMARelevantOP/PB claimasthmaRelevantOP/PB claimasthmaRelevant IP claim COPDCOPDRelevantOP/PB claimCOPDRelevantOP/PB claimCOPD

30August 26Example Pulmonary PACsEpisode Components: PACs Costs are separated by “typical” care from costs associatedwith Potentially Avoidable Complications (PACs) Can stem from poor coordination, failure to implementevidence-based practices or medical error PACs for chronic conditions and some acute conditions have beenendorsed by the NQF as comprehensive outcome measures1AcuteExacerbation ofCOPD / perRespiratoryInfectionSepsisPneumonia Expected costs of PACs are built in as an incentive towards ashared savings Only events that are generally considered to be (potentially)avoidable by the caregivers that manage and co‐manage the patientare labeled as ‘PACs’ Examples: exacerbations, ambulatory‐care sensitive admissions, andinpatient‐based patient safety features1 gnment with NQFFour unique PAC measures have beenendorsed by the National QualityForum (NQF) with 6 more submittedthis year.

31August 26Episode Components: LevelingThe grouper uses the concept of leveling (1-5), in which individual associated episodes mayget grouped together into a “bundles” as you move higher in the levels.54321As you move higher up in levels, associatedepisodes get grouped together into a bundle, inour example, pneumonia and upper respiratoryinfection roll up under Asthma or COPDIn Level 1, claims are grouped into definedepisodes, for example pneumonia and upperrespiratory infection, exist as separateepisodes at level 1.

32August 26Leveling for Asthma and COPD At level 1, both pneumonia and upper respiratory infection are separate episodes At level 5, they become PACs for the respiratory episodesLevel 5Level 5COPDAsthmaLevel 1Level COPDUpperrespiratoryinfection

33August 26Risk Adjustment for EpisodesMake “apples-to-apples” comparisons between providers by accounting fordifferences in their patient populationsTakes the patient factors (co-morbidity, severity of condition at outset, etc)out of the equationSeparate risk adjustment models are created for ‘typical’ services and for‘potentially avoidable complications’More information can be found at ability%20of%20Prometheus%20Measures 0.pdf

August 2634Inclusion and Identification of Risk FactorsRisk Factors Patient demographics – Age, gender, etc Co-morbidities Subtypes - Markers of clinical severity within an episodePatient related risk factorsEpisode related risk factorsIdentification of Risk Factors Risk factors come from historic claims (prior to start of an episode) and same list isapplied across all episode types Subtypes identified from claims at start of the episode and specific to episode type

August 2635Inclusion and Identification of Risk FactorsRisk Factors Patient demographics – Age, gender, etc Co-morbidities Subtypes - Markers of clinical severity within an episodePatient related risk factorsEpisode related risk factorsExamples of SubTypesASTHMA Subtypes: NoneIdentification of Risk FactorsCOPD Subtypes: Emphysema, Obstructive Chronic Bronchitis Risk factors come from historic claims (prior to start of an episode) and same list isapplied across all episode types Subtypes identified from claims at start of the episode and specific to episode type

36August 26Description of Asthma EpisodeLook back (30 days)Episode cost captured through one year time periodTriggerConfirming(Confirming for IP)TriggerTrigger1. Inpatient claim with asthma as principal diagnosisOR2. Outpatient or professional billing claim (office visit) withasthma as diagnosis AND another of the same at least 30days after first trigger.Included in bundle: All typical and PAC services for asthma during the durationof the bundle PACs include, but are not limited to:‐ Acute exacerbations‐ Upper respiratory infection‐ Pneumonia‐ Respiratory failure / insufficiency‐ Sepsis

37August 26Description of COPD EpisodeLook back (30 days)Episode cost captured through one year time periodTriggerConfirming(Confirming for IP)TriggerTrigger1. Inpatient claim with COPD as principal diagnosisOR2. Outpatient or professional billing claim (office visit) withCOPD as diagnosis AND another of the same at least 30days after first trigger.Included in bundle: All typical and PAC services for COPD during the duration ofthe bundle PACs include, but are not limited to:‐ Acute exacerbations‐ Upper respiratory infection‐ Pneumonia‐ Respiratory failure / insufficiency‐ Sepsis

August 26Part IIA. Asthma and COPD episodes – Impressions of data available forvalue-based contracting38

39August 26Asthma episodes account for nearly 335M in AnnualMedicaid SpendAnnual Age Distribution ofBeneficiaries with an Asthma EpisodeAnnual Episode Volume 651222K EpisodesTotal Annual Cost ofAsthma (to the State)2818 - 4421Female145 - 6412Male49 355M12 - 1714Average Costs per Episodefor Beneficiaries with anasthma episode6 - 1123 1,2005040302010ThousandsCosts Included: Fee-for-service and MCO payments (paid encounters); Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.Source: 01/01/2012 – 12/31/2013 Medicaid claims16 62760120180102030405060Thousands

40August 26COPD episodes account for nearly 114M in AnnualMedicaid SpendAnnual Age Distribution ofBeneficiaries with a COPD EpisodeMaleFemaleAnnual Episode Volume60K Episodes1 6513145 - 64Total Annual Cost of COPD(to the State)61618 - 4412 114M1Average Costs per Episodefor Beneficiaries with aCOPD episode12 - 172 1,4786 - 11161412108642ThousandsCosts Included: Fee-for-service and MCO payments (paid encounters); Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.Source: 01/01/2012 – 12/31/2013 Medicaid claims2 6318103024681012141618Thousands

41August 26Four Important Costs Drivers for Pulmonary Episodes arePrice, Volume, PACs and Service MixPriceVolumeCost DriversThe price of a service can vary based on providers’ owncosts (e.g. wages).In NYS, we will in the beginning only use pricestandardized data.The volume of services rendered (e.g. doing 1 lung volumetest vs. 3 in the first 2 months).PACsPotentially avoidable complications (e.g. exacerbations).Service MixThe mix of services and intensity of care received duringthe episode (e.g. inpatient vs. outpatient point of care).

42August 26PAC Costs Represent 528M of All Asthma and COPD Costs% Potentially Avoidable Complication CostsRelative to Total Costs of ASTHMA Episodes% Potentially Avoidable Complication CostsRelative to Total Costs of COPD EpisodesTotal ASTHMA spend: over 2012-2013: 879MTotal COPD spend over 2012-2013: 276MPAC Costs, 361.2M, 41%Typical Costs, 517.9, 59%Costs Included: Fee-for-service and MCO payments (paid encounters); Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.Source: Fee-for-Service and Managed Care encounter records for Pulmonary Bundle Patients in CY2012-2013. Source: HCI3Typical Costs, 109.6M, 40%PAC Costs, 166.7M, 60%

43August 26The Top 10 Asthma PACs Incur 93% of the Total Costs forAsthma’s Potentially Avoidable ComplicationsTotal PAC Cost 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000acute exacerbation of copd, asthmaThousands 160,000 180,000 174.7MUpper Respiratory Infection 63.1MPneumonia 41.9MRespiratory Failure 16.4MSepsis 15.6MRespiratory Insufficiency 5.2MFluid Electrolyte Acid Base Problems 5.2MAcute esophagitis, acute gastritis, duodenitis 4.5MHypotension / Syncope 3.9MComa, persistent vegetative state 3.5M0100,000200,000300,000PAC occurence400,000 500,000 600,000# PAC OccurenceTotal PAC cost700,000800,000900,000 1,000,000

44August 26The Top 10 COPD PACs Incur 41% of the Total Costs for COPDPotentially Avoidable ComplicationsTotal PAC Cost 0 10,000 20,000 30,000 40,000 50,000Thousands 60,000 70,000acute exacerbation of copd, asthma 62.9MUpper Respiratory Infection 24.7MPneumonia 17.7MRespiratory Failure 17.5MSepsis 16.0MFluid Electrolyte Acid Base Problems 2.6MRespiratory Insufficiency 2.5MAcute esophagitis, acute gastritis, duodenitis 2.1MHypotension / Syncope 1.7MGI Bleed 1.6M020,00040,000PAC occurence60,00080,000100,000# PAC OccurrenceTotal PAC cost120,000140,000160,000

August 26The Average Cost per Asthma Episode is Between 517 and 1,258Brighter red means higher costs45

August 26The Actual Minus Expected Cost per Asthma Episode isBetween - 424 and 119Brighter red means actual costs are much higher than expected46

August 26The Average Cost per COPD Episode is Between 821 and 2,512Brighter red means higher costs47

August 26The Actual Minus Expected Cost per COPD Episode is Between- 217 and 770Brighter red means actual costs are much higher than expected48

49August 26Example Drilldown: Asthma in the BronxActual Minus Expected Cost/EpisodeLighter Blue Better Cost Performance

50August 26Example Drilldown: Asthma in the BronxTop 10 Highest Total Cost ZIP Codes in the Bronx

The 2nd CAG Meeting will be on October 7, 2015 in New York CityMeeting 2 Pulmonary Episodes Definition Recap Pulmonary Episodes Outcome Measures - I

Pulmonary episodes represent 1.16B over two years ASTHMA, 879M, 76% COPD, 276M, 24% Cost Composition of Pulmonary Episodes Total Pulmonary Costs: 1.16B in two years (2012-2013) ASTHMA, 443K, 79% COPD, 120K, 21% Volume Makeup of Pulmonary Episodes Total Pulmonary Episodes: 564K in two years (2012-2013) 8 Costs Included:

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