Bruce Kinosian, MD
University of Pennsylvania
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Changing from quantity to value in fee-for-service
Medicare.
If not in an Advanced Payment model, will be subject
to VBPM.
Comparison is to one’s specialty, and applied at the
TIN level.
A small housecall practice in a large health system
will have little effect (unless the system passes the
modifier through to individual practice)
Housecall Practices that are a large share of their TIN
will be potentially affected with a 4% reduction
because of the patients they treat, NOT because of
the value they provide.
Payment at risk is -4.0%, with potential upward adjustment of up
to +4.0x (‘x’ represents the upward payment adjustment factor)
Proposed CY 2017 VM Amounts
Cost/Quality Low Quality Average Quality High Quality
Low Cost
+0.0%
+2.0x*
+4.0x*
Average Cost
-2.0%
+0.0%
+2.0x*
High Cost
-4.0%
-2.0%
+0.0%
* Eligible for an additional +1.0x if reporting clinical data for
quality measures and average beneficiary risk score in the top 25
percent of all beneficiary risk scores
3
5.6%
11.8%
35%
2013 Performance
2015 Payment Adjustment
Category
Cost
Quality
# TIN
Total
Payment
Adjustment Amount
Category 1
Avg
High
12
$224M
$10.9M
Low
Avg
2
$8.7M
$424,383
Avg
Avg
81
$998M
Un-Tiered Insufficient data
853
$8.3B
$0
$0
Category 2 (did not participate in
319
$1.1B
-$10.9M
Category 1
PQRS)
Avg
Low
7
$49.2M
-$246,010
High
Avg
1
$4.3M
-$21,321
High
Low
3
$15.6M
-$156,759
Quality Measures
• Reporting through GPRO-Web Interface, Qualified PQRS Registry, EHR,
or 50% of EPs reporting individually (same as 2016)
• Patient Experience Measures: CAHPS for PQRS
•Optional for groups with 2-99 EPs
•Required for all groups with 100+ EPs
• Outcome Measures: Same as 2015 (see Appendix Slide 43)
•All Cause Readmission
•Composite of Acute Prevention Quality Indicators (bacterial pneumonia,
urinary tract infection, dehydration)
•Composite of Chronic Prevention Quality Indicators (COPD, heart failure,
diabetes)
Cost Measures
• Same as 2016
• Total per capita costs measures (Parts A & B)
• Total per capita costs for beneficiaries with 4 chronic conditions:
•Chronic Obstructive Pulmonary Disease (COPD)
 Heart Failure
•Coronary Artery Disease
 Diabetes
• Medicare Spending Per Beneficiary measure
Value Modifier
Components
Cost Measures
2015
Finalized Policies
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Total per capita costs
measure (annual
payment standardized
and risk-adjusted Part A
and Part B costs)
Total per capita costs
for beneficiaries with
four chronic conditions:
COPD, Heart Failure,
Coronary Artery
Disease, Diabetes
2016
Finalized Policies
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Same as 2015, and
Medicare Spending
Per Beneficiary
measure (includes
Part A and B costs
during the 3 days
before, through 30
days after
discharge following
an inpatient
hospitalization)
2017
Proposed Policies
Same as 2016
Benchmarks
Group Comparison
Specialty Adjusted
Group Cost
Specialty Adjusted
Group Cost
Payment at Risk
-1.0%
-2.0%
-4.0%
Application of the
VM to Participants of
the Shared Savings
Program, Pioneer
ACO Model, and the
CPC Initiative
Not Applicable
Not Applicable
Applicable
IAH 3.4
PACE 2.4
Cost/Frailty
HC
HC
Mean
Medicare Number
Payments Services
HC Mean
Service
Use
Months
Hospital
Acute
Care Use
Rehab.
Service
Use
Death
Rate
HC in
Year Users
Total
Medicare
Payments
2008
22,425
$26,072
$508
6.65
2.44
44%
67%
14%
2009
24,193
$27,191
$546
6.82
4.68
42%
69%
14%
2010
26,972
$27,614
$566
6.85
4.53
43%
70%
14%
2011
29,370
$27,366
$566
6.89
4.71
42%
70%
14%
2012
31,013
$26,946
$574
6.96
4.73
41%
70%
15%
Calendar
Year
Average Medicare spending equivalent to those
with 6+ chronic conditions
HC in
Year
Users
New HC
Users
New HC
Users with
Base Period
New IAH-Q
qualified HC
Users
2008
22,425
22,425
0
0
2009
24,193
11,548
9,803
3,428
2,782
19%
2010
26,972
12,188
9,989
3,611
5,045
21%
2011
29,370
12,588
10,576
3,912
7,089
21%
2012
31,013
12,949
10,950
4,370
9,004
21%
71,698
71,698
41,318
15,321
620,260
258,980
219,000
87,400
Calendar
Year
Total
Population
2012
End of Year
Cumulative Mortality
Census
rate
180,080
Over 620,000 Medicare Beneficiaries received HBPC in
2012, of which
180,000 (30%) were Independence at Home Qualified
0.45
0.4
0.35
5%/iahq
geripact 5%/5% iahq
hbpc5%/5% iahq
0.3
0.25
0.2
0.15
0.1
0.05
0
1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23
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Clinical Instability as patients enter housecalls
High mortality
High prevalence of dementia and frailty
Poor performance of HCC model among the
top 5% of high cost patients (~ 20%
underestimate)
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Year 1
Year 2
Year 3
Terminal Year Cost (predicted)
Terminal Year Cost (observed)
Non-terminal year cost (predicted)
Total
Characteristic
Share of IAH Eligibles
2+ Major Chronic Disease
100%
Alzheimers/Dementia
50%
CHF
55%
COPD/CRD
49%
Diabetes
50%
Risk Adjustment must
include Dementia HCCs
(V21 model)
$4,000
$3,500
$3,000
$2,500
$2,000
$1,500
Observed
$1,000
HCC-Expected
$500
$0
Low Cost
Moderate
High Cost
(<$800)
Cost ($800-
(>$900)
$900)
Increased skew of FFS county cost
distribution— the means don’t
reflect the tail
Richmond-$682
DC-$760
Phil-$806
UPENN $3125
WHC $3061
VCU $3147
IAH –
$2800-$3100
Cost
0.45
Expected
0.4
Readmissions
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15
180
160
140
120
100
80
60
40
20
0
Expected
ACS/1000
Dual ACS Benchmark
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Use the HCC Version and Frailty Adjuster
Used for PACE– but also requires PACE rates
to approach observed costs, or augmented
Frailty Adjuster if use FFS benchmark rates
Better account for Mortality in Risk
Adjustment
Greater Outlier trim for high cost
beneficiaries– but may be up to 1/3-1/2 of
housecall population
Separate weighted strata for Housecall –
associated beneficiaries