2 - Provider Reimbursement Flashcards

1
Q

key learnings from disease management programs that ACOs should apply to be successful

A
  1. need high quality data analytics, as close to real-time as possible
  2. medical records need to have analytical sophistication and workflow capabilities. ACOs emphasize EMRs but often just a repository
  3. systems need to be aggregated before they can usefully support the ACO
  4. importance of economics
    –changing patient behavior in a way that produces measurable financial outcome is long and difficult task
    –programs need to be focused on patients who represent greatest opportunity for cost reduction
  5. the importance of planning and understanding the opportunity
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2
Q

structure of medicare ACOs

A
  1. ACO is a network. either physician practice based or hospital based. shares responsibility for providing care to patients.
  2. two models for gainshare
    a) one sided: 50/50 gains
    b) two sided: ACO more gain share, at risk for loss
  3. must meet requirements to share savings
    a) quality standards
    b) savings surpass hurdle rate: 2-4%. higher for smaller ACOs
  4. ACO must manage all medical health care needs of at least 5K medicare beneficiaries for at least 3 years
  5. patients do not enroll. they are attributed based on plurality of care
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3
Q

ways in which provider group based ACOs are expected to generate savings

A
  1. implementing care coordination
  2. reducing need for tests via access to integrated medical records and consistent management by the physician
  3. developing a network of efficient providers for referrals and limiting the use of less efficient and more expensive providers
  4. focusing on quality, which will result in fewer unnecessary services. emphasizing preventive services
  5. redirecting care to cost efficient providers
  6. reducing duplication of services and unnecessary care
  7. preventing medical errors
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4
Q

criteria for a beneficiary to be assigned to a participating ACO

A
  1. record of medicare enrollment
  2. at least one month of Part A and Part B enrollment, no A or B only months
  3. no group/private health plan enrollment
  4. may be assigned to only one medicare shared savings initiative
  5. beneficiary must live in the US or territories
  6. beneficiary must have a primary care service with a physician at the ACO
  7. beneficiary must receive the largest share of their primary care services from the participating ACO
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5
Q

steps in the process for CMS to assign beneficiaries to an ACO

A
  1. at least one primary care service from a pcp and more primary care services from the ACO than other ACO
    or
  2. no primary care provider -> received primary care service from specialty care provider, more services from ACO than other ACO
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6
Q

calculation of average per capita expenditure for ACOs

A
  1. separate for ESRD, disabled, aged/dual, aged/non-dual
  2. defined as total parts A and B FFS payments from any provider for eligible months
  3. 3 months runout, CF applied by CMS
  4. average per capita expenditure = sum(claims * exposure) / sum(exposure)
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7
Q

risk adjustment approaches for updating benchmarks for the performance years for medicare ACOs

A
  1. newly assigned beneficiaries: ACO prospective CMS-HCC risk score recalcuated to adjust for changes in severity and case mix
  2. continuously assigned beneficiaries: risk ratio of HCC score to benchmark year 3 by enrollment type -> wtd avg. if > 1, demographic scores used. if < 1, HCC used
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8
Q

formulas for ACO’s initial and adjusted benchmark costs for performance year 1

A

C0 =
(1/3)CB1(1+tB1)(1+tB2)(RB3/RB1) +
(1/3)CB2(1+tB2)(RB3/RB2) +
(1/3)
CB3
[originally .6 / .3 / .1]

updated benchmark
C’PY1 = C0 * RPY1 / RB3
add absolute increase in National Part A and B PMPY

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9
Q

Methodology for calculating ACO shared savings payments, one-sided model

A
  1. calculate C’PYi
  2. get actual costs
  3. savings = C’PYi - actual costs
  4. savings rate: 50% for one-sided
  5. shared savings rate = max sharing rate * quality performance score [avg of categories]
    shared savings = savings * ssr
    -capped at 10% in one sided model
    -must achieve minimum savings rate
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10
Q

criteria to be considered an Advanced Alternative Payment Model (APM)

A
  1. involves more than nominal risk of financial loss
  2. includes a quality measure component
  3. has the majority of participants using certified EHR technology
  4. examples include: two-sided risk ACOs, medical homes expanded by CMS’s innovation center
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11
Q

ACO Tracks / gain/loss rates (as of 2018)

A

Track 1: one sided. 50% of gains, max 10% of benchmark
Track 1+: two sided. 50% of gains up to 10%. 30% of loss up to 4% benchmark OR 8% of ffs revenue
Track 2: two sided. 60% gains up to 15%. loss between 40% and 60% up to 5% or 10%
Track 3: two sided. 75% gains up to 20%. 40-75% loss up to 15%

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12
Q

description of the unintended incentive in ACO payment models

A
  1. benchmarks to be recalculated on 3 year period, 60% weight on recent year
  2. incentivizes increased spending in recent year
  3. removes incentive to create savings in that year
  4. may result in higher than FFS spending
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13
Q

proposed strategies for improving incentives in ACO payment models

A
  1. change benchmark weights to be equal
  2. introduce yardstick competition
    –use local benchmark or other Medicare providers
    —introduces competition
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14
Q

elements of network management

A
  1. articulate the goals of the network
  2. comply with applicable regulations
  3. ensure quality standards met
  4. manage cost
  5. manage risk
  6. evaluate the network on an on-going basis
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15
Q

goals of a provider network for each major stakeholder

A

administrator:
1. grow / remain financially stable
2. meet needs of specific population
3. preserve market share
4. provide negotiation leverage thru size

employer:
1. offer employees a benefit suite that may include network options
2. balance trade off between cost of broader network and employee satisfaction with benefits
3. limit provider disruption

consumer:
1. minimize total cost of coverage (payroll contrib + cost share)
2. existing physicians in network
3. local network with good reputation
4. administration of plan’s benefits smooth, no surprises

provider:
1. earn fair and predictable income
2. spend as little time as posible on administrative functions

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16
Q

three primary domains of network adequacy

A
  1. provider composition
  2. geographical access
  3. consumer protections from participating providers
    –no balance billing
    –no member hold harmless
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17
Q

steps in selecting and applying a quality measure

A
  1. establish validity of measure with lit review/analysis
  2. assign measure to domain (goal of measure)
  3. identify algorithm for determining if measure has been met
    – structural [qualifications, staffing]
    – process [administration of care]
    – outcomes [mortality rates]
  4. update systems, work streams, documentation
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18
Q

levers available to administrators to help control costs

A
  1. limiting benefits deemed not medically necessary
  2. managing the disease burden
  3. utilization management
  4. encouraging provider efficiency
    —portfolio method or TCOC method
  5. reimbursement methodology
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19
Q

categories of reimbursement methods

A
  1. FFS: fee sched, discount, DRG, per diem
  2. FFS with link to quality and value - activities based, not results based
  3. APM built on FFS
    – results based
    – episodic
    – risk bonus/penalty
  4. population based
    – TCOC based
    – capitation, global budgets, percent of premium
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20
Q

advantages and disadvantages of tiered network health plans (TNHP)

A

advantages
–TNHP design savings: lower cost share, lower net claim cost, lower premium
–better health: quality care
–significant cost differential: drive members to preferred provider

disadvantages
–markets with limited provider competition
–service vs product: hard to compare care quality
–sometimes cost differential is negligible
–state requirements: network adequacy

anticompetitive and transparency laws, significant cost differentials, high quality care, sufficient network size mitigate weaknesses

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21
Q

distinct steps to tiering providers

A
  1. limit preferred providers to those meeting a quality standard
  2. for providers passing that quality standard, draw a line at a low-cost percentile, or choose the lowest cost provider in a designated region
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22
Q

components of the TNHP pricing formula

A
  1. claims under control: N% - % of incurred claims under control of non-pref providers
  2. cost differential: P% = 1 - (avg pref cost / avg non pref cost)
  3. member liability differential: M% = 1 - (AV non-pref / AV pref)
  4. shift = % dollars switching

TNHP savings = N% * [M% + shift * (P% - M%)]
–equilibrium when M% = P% - incurred claims cost same despite member choice

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23
Q

ways in which bundled payments have been used

A
  1. by providers to attract more business, including from self-pay patients and medical tourism
  2. by providers to engage physicians (surgeons specifically)
  3. by providers to gain cooperation of physicians to reduce hospital cost
  4. by payers to reduce payments
  5. by payers to encourage patients to use lower-cost or higher-quality providers
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24
Q

considerations in contracting for bundled payments

A
  1. defining the episode: trigger date, end date, included services
  2. evaluating catastrophic risk: outlier analysis/stop loss analysis
  3. financial stability for low case loads
  4. determining provider allocation of funds (with incentives for quality care in mind)
  5. distinguishing case severity
  6. quality outcome requirements
  7. administrative complexity of supporting the contract
  8. risk sharing alternatives
  9. potential for increased utilization (dont incent increased util to get larger share)
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25
Q

process for developing episode based measures of quality performance using a claims database

A
  1. opportunities are identified
  2. quality measurement event opportunity is attributed to physicians using fixed attribution rules
  3. compliance rate is calculated for each physician by comparing opportunities with success
  4. performance can be assessed in terms of a relative compliance rate
26
Q

major advantages of episode based profiling

A
  1. administrative feasibility
  2. minimal administrative burden for data collection
  3. comparable performance against defined standards
  4. episode view can be considered more patient centered
27
Q

limitations of episode based profiling

A
  1. misidentification of high and low performing physicians
  2. comparative bias of providers
  3. physicians cost efficiency scores may be inaccurate if:
    –episode responsibility attributed incorrectly
    –cost outliers distort estimates of underlying performance
    –episodes considered in profiles are not representative of a physicians usual practice
    –risk adjustment is inadequate to control for effects of patients comorbid conditions
    –number of episodes available for profile calculations is insufficient for reliable estimation
  4. inclusion of hospital costs in episode based profiles has challenges
    –cost efficiency measures can be heavily influenced by hospital costs
    –hospital costs are largely beyond physician control
    –adverse impact for physicians practicing in high cost settings, academic medical centers
28
Q

how episode based profiling is likely to improve and become more standardized over time

A
  1. electronically submitted claims will increase accuracy
  2. fully documented claims have more reliance episode profiles
  3. comorbidities and other risk adjustment factors will be credited more accurately
  4. organized and supported practice infrastructure will distinguish performance characteristics
  5. catalyze medical profession to development administrable evidence based performance measures
29
Q

factors that determine validity and reliability of cost profiles

A
  1. validity: indicates whether method of assigning episodes of care to physicians and creating summary scores will accurately represent phys economic performance
  2. reliability - 3 factors:
    –number of observations (episodes of care)
    –variation among physicians in their use of resources to manage similar episodes
    –random variation in the scores
30
Q

steps to construct a physician summary cost profile

A
  1. group claims into meaningful clinical categories (episodes)
  2. determine observed episode costs based on allowed charges
  3. attribute episodes to physicians
  4. construct physician summary cost profiles:
    –avg cost by episode type
    –adjust by risk score
    –cost profile = sum(observed cost)/sum(expected cost)
31
Q

equation for physician-specific reliability

A

= phys to phys variance / (phys to phys variance + phys-specific error variance)

1) large variations in cost would have large phys-specific variation
2) phys to phys variance is larger when there is a wider distribution of cost profile scores

32
Q

significant findings in the reliability of physician cost reporting

A
  1. median reliability had wide range by specialty
  2. overall, majority of physicians did not have cost profiles meeting common thresholds of reliability
  3. doubling episodes only produced modest gains
  4. recommended that users of cost profiles directly assess reliability
  5. surgical specialties had low reliability scores
  6. opportunities for cost control still exist among physicians with more reliable scores
  7. misclassification presents difficulties achieving cost control objectives
  8. developing better measures of cost performance at the physician level appears to be the most promising method to increase reliability of cost profiles
  9. consumers, phys, purchasers all at risk of being misled
33
Q

practical issues that have determined the success or failure of previous value-based arrangements

A
  1. engaging all stakeholders is important (policymakers, actuaries, providers)
  2. payment reform is organization specific, not one size fits all
  3. results of payment reform are decidedly mixed with both successes and failures
  4. success in provider payment arrangements depends on good holistic risk management by the payment reform team
  5. organizations need various qualities in order to success under payment reform
  6. insurance companies have an important role in payment reform since they can pool and reduce insurance risk. providers must be required to take on some risk, which they must carefully monitor
  7. mechanics and administration of payment models that incorporate provider risk have improved since 1990s consumer backlash
34
Q

definitions related to payment reform

value based arrangement
payment reform environment
payment mode
service delivery model

A
  1. value based arrangement: reimburses based on quality measures like outcomes and efficiencies, not volume
  2. payment reform: environment where more contracts more to value based
  3. payment model: arrangement between payer and provider
  4. service delivery model: manner in which providers organize and deliver care to patients
35
Q

actuary’s role in payment reform

A
  1. lead pricing exercise
  2. quantify risks - help provider understand risks associated with payment models
  3. calculate correct price for selected payment model
  4. project and model cash flows
36
Q

types of risk associated with payment arrangements from the providers perspective

A
  1. utilization risk: utils impact profitability
  2. technical risk: technical elements of contract
  3. insurance risk: variation in demand, differences in utilization within segments of population
    –age, gender, acuity. # high cost cases. year to year variation in demand. proportion of zero cost mems
  4. performance risk - inefficiency, suboptimal quality, high cost of care
37
Q

types of provider payment models

A
  1. FFS
  2. Global cap
  3. Shared savings (usually FFS + util vs benchmark)
  4. DRGs
  5. Bundled payments
  6. Reference pricing
  7. provider excess loss reinsurance (usually paired with other)
  8. pay for performance - can be part of any arrangement to incentivize quality. adds performance risk
38
Q

risks to provider under FFS

A
  1. utilization risk: profit up with utils
  2. technical risk: very low
  3. insurance risk: very low
  4. performance risk: may exist if claims administrators do not monitor nonspecific codes
39
Q

risks to provider under global cap

A
  1. utilization risk: opposite of FFS. util increase profit decrease
  2. technical risk: high. lots of allocation of funds
  3. insurance risk: 100% on provider
  4. performance risk: high risk, provider has 100% financial responsibility of care
40
Q

risks to the provider under shared savings

A
  1. utilization risk: hard to quantify. complex contracts
  2. technical risk: very high. complex contracts
  3. insurance risk: benchmark vs year to year changes
  4. performance risk: significant risk regarding if care management efficiencies can be achieved, benchmark met
41
Q

risks to provider under DRG/case rates

A
  1. utilization risk: increased admissions lead to increase profits. length of stay must be managed (more days = less profit)
  2. technical risk: low-med, fairly simple, well known
  3. insurance risk: provider at risk for LOS but not incidence
  4. performance risk: risk of discharging patients too early / readmission risk
42
Q

risks to provider under bundled payments

A
  1. utilization risk: profit up with episodes, episodes must be managed
  2. technical risk: high. hard to define conditions/coordinate care
  3. insurance risk: provider at risk for patients where episodes cost more than avg
  4. performance risk: risk related to proper discharge planning and communication
43
Q

risks to provider under reference pricing

A
  1. utilization risk: mems less likely to use provider services as out of pocket share increases
  2. technical risk: risk related to educating policyholder
  3. insurance risk: high cost care risk shifted to patient
  4. performance risk: unhappy patients
44
Q

risks to provider under provider excess loss reinsurance

A
  1. utilization risk: risk shifted to reinsurer
  2. technical risk: varies by contract. can be simple
  3. insurance risk: high outlier costs mitigated
  4. performance risk: dependent on structure of policy
45
Q

domains of quality from the agency for healthcare research and quality

A
  1. access to care (ease to obtain service)
  2. structure of care (appropriate providers, up to date tech)
  3. process of care (care to appropriate subpopulations. readmissions)
  4. outcome of care (effective care)
  5. experience of care (surveys)
46
Q

factors to consider when modeling payments and cash flows for a provider payment model

A
  1. unintended behaviors due to incentives created by payment model
  2. factors that could jeopardize achievement of forecasted results
  3. how results from model test will be replicated
  4. will structure and dimensions of payment model change over time
  5. phase in
  6. how will payment model promote continuous improvement of service delivery model
  7. what key factors, including other delivery and payment reforms, may affect progression?
47
Q

formula for determining medicare allowed amounts

A
  1. weights:
    -RVUs:
    —work/practice
    —facility/cost of living
    —malpractice
    -GPCI - zip code
  2. sum(GPCI * RVU) * conversion factor
  3. adjusted for various reasons, including provider type and place of service
48
Q

Profit formula for ACOs in the MSSP

A

Net gain/loss =
- revenue reductions
+ bonus/share of revenue reductions
- startup costs of the ACO
- administrative costs of operating the ACO
+ reduction in direct expenses

49
Q

Considerations when negotiating terms of commercial ACO contracts

A
  1. target costs - how baseline developed, how rebased/how often
  2. risk adjustment
  3. trend
  4. shared savings
  5. attribution
  6. random variation
  7. stop loss
  8. data and reports
  9. quality - measures / reliability
  10. infrastructure cost support
50
Q

Elements of a DRG contract

A
  1. DRG/case rate schedule - case rate + initial LOS + per diem after
  2. Max days (e.g. initial LOS)
  3. Carve-outs: specialty drugs, implant devices
  4. stop loss
  5. transplants - generally separate
  6. readmissions
51
Q

steps for pricing bundled payments

A
  1. obtain claims data
  2. select DRGs or conditions - requires sufficient volume, population with similar treatment patterns, potential savings
  3. define the episode: time period, mix of services included
    –anchor stay: period of time between admit and discharge
    –post-discharge period / post-anchor
    –post-episode period
  4. define exclusion criteria - s/b easy to implement, not overly specific
  5. estimate cost of the bundle
  6. identify savings opportunities - example: discharge knee replacement patients to home instead of rehab center
52
Q

major issues with pay-for-performance methods

A
  1. unintended incentive to avoid the most severely ill patients
  2. gaming the system by miscoding diagnoses or services
  3. selecting patients on the basis of the likelihood of a positive outcome
  4. compliance with treatment protocols rather than need
  5. unmeasured objectives could be ignored
53
Q

functions (or components) of patient-centered medical homes

A
  1. comprehensive care: provided thru several different care providers
  2. patient centered: relationship based, educate patients to allow them to define care
  3. coordinated system: communications across providers
  4. accessible services: providing multiple channels for patient to get info or care
  5. quality and safety: quality improvement measures while taking into account patient’s progress, concerns, well-being
54
Q

roles of the payment reform team

A
  1. actuary: quantify risks and prepare financial models
  2. CFO: set budget, allocate resources
  3. clinicians: provide high quality care, achieve satisfaction, good outcomes
  4. coding specialists, data analysts, IT specialists: support other team members with timely accurate info
  5. policymakers: address systematic issues like PCP shortages
55
Q

qualities an organization needs to succeed under payment reform

A
  1. highly integrated system
  2. efficient care management initiatives
  3. more efficient health system than the rest of the market
  4. select and restricted networks
  5. collaborative relationship between the provider org and payers to reduce costs
  6. reasonable methods to establish capitation rates, episode payments, and other payments
  7. equitable methodology for allocating global capitation payments or quality incentives among the individual participating providers
56
Q

categories of value based quality performance measures used by PBM, green shield canada

A
  1. medication adherence - portion of days covered for
    –hypertensions
    –cholesterol (statins)
    –diabetes
  2. disease management measures
    –statin use in persons with diabetes
    –suboptimal control of asthma
    –absence of controller inhaler in asthma patients
    –pharmacist health coding
  3. patient safety - high risk medication use in elderly
57
Q

reasons why medication-use quality measures were used in value based pharmacy initiative
canada

A
  1. address areas of high priority in the health care system, in terms of DM and patient safety
  2. using performance metrics can have a direct impact on pharmacists interventions, positively impact quality, outcomes, reduce health costs
  3. easy to track and understand
  4. align with performance indicators tracked by various provincial quality orgs
58
Q

phases of the value based initiative rollout in canada

A
  1. performance reflection - pharmacies get scorecards w performance info
  2. performance distribution - score/star rating made available to plan members
  3. performance accountability - reimbursement tied to scores
59
Q

objectives associated with implementing a value based pharmacy initiative

A
  1. providing pharmacies with performance feedback to facilitate improvement
  2. identifying the high needs patients who would benefit from intervention and additional support
  3. support the change from fee-based dispensing to the delivery of high quality patient-centered care
60
Q

components of the value based care capabilities framework

A
  1. VBC overall strategy: define objectives and quantify impacts to organizations
    2-4 interdependent
  2. high performing network management - high quality, efficient care
  3. population health management: care management programs supporting network in addressing needs
  4. enterprise financial risk management: upstream (payers) and downstream (providers)
  5. data management - data will support VBC performance management process
  6. consumer engagement
  7. analytics and reporting
  8. enabling technology
  9. business operations excellence
  10. product leadership - responsibility and accountability
  11. organizational change and talent acceleration - key to identify required skill sets to support VBC and assess current talent and determine gaps
61
Q

provider reimbursement model continuum for VBC

A

high to low provider risk and sophistication
1. global payment / capitation
2. shared risk
3. shared savings
4. bundle payment (risk among providers)
5. bundle payment (single bearer of risk)
6. pay for performance
7. pay for activity / coordination
fee for service

62
Q

metrics and data used by actuaries to evaluate the risks providers face moving to VBC payments

A

Metrics
1. mix of business for revenues and margins across various payers
2. mix of business by service, provider type, of place of service
3. cost to charge ratios and expected margin
4. fixed and variable costs
5. capital investments current and planned
6. quality measures
7. current revenue and cost contracting arrangements
8. market share in total, by attributed populations and service line
9. amount of risk provider is legally allowed to take
10. types of service in which a provider is legally allowed to have ownership
11. pharmacy services, both med and retail
12. full claims dataset

Marketplace Data
1. uninsured vs insured populations in the area and provider services
2. insured populations broken out by segment
3. projections for population growth or contraction
4. competitors, traditional providers, or new entries
5. market opportunity analysis
6. disruption
7. local, state, regional, national changes in policy