1

2019 Home Care Conference

Home Care Association of Washington

May 1, 2019

HHVBP – Deep

Dive into the Data

and CY 2019

Changes

Chris AttayaVP of Product Strategy

Agenda

• HHVBP Overview

• CMMI First Annual Report

• CMMI Payment and Adjustment Reports – PY 2017

• Final Rule on HHVBP for PY 2019

• VBP Trends through Calendar 2018

• Data on the New Composite Metrics

HHVBP Overview

HHVBP

• 5 year pilot starting with Performance Year in 2016

• Bonus or penalty up to 3% first year then - 5%, 6%, 7%, 8%

• Baseline Year of 2015 used for calculating the median (achievement threshold) and mean of top decile (benchmark)

• Baseline scores are state specific

• For CY 2016/2017 - 17 OASIS/Claims/HHCAHPS measures used along with 3 New Measures

• Up to 10 Points for Achievement and Improvement for each measure – get the higher of the two

Measures by NQF Domain (PY ’16, PY’17)

DOMAINS

1) Patient and Caregiver Centered Experience 2) Clinical Quality of Care

3) Communication & Care Coordination 4) Population Health

5) Efficiency and cost reduction 6) Patient Safety

Points on Achievement and Improvement

Total Performance Scoring (TPS)

• 17 OASIS/HHCAHPS/Claims based measures are used in the TPS unless an agency does not have 20 or more episodes per measure - Accounts for 90% of the score

• Three “New Measures” account for the 10% of the score

• If an HHA does not meet this threshold to generate scores on five or more of the Clinical Quality of Care, Outcome and Efficiency, and Person and Caregiver-Centered Experience measures, no payment adjustment will be made

• Bonus and Penalties are based on the relative position of your TPS scores to the other providers in your cohort (large or small)

Total Performance Scoring (Cont.)

Total Performance Scoring (Cont.)

TPS Scoring – Linear Exchange Function

TPS Examples

CMMI First Annual Report

CMMI First Annual Report on HHVBP

Published in July 2018 including 67 agency interviews

Key Findings

• Overall improvement in TPS scores• Both HHVBP and non-HHVBP agencies saw improvements

• Non-HHVBP agencies may have been responding to CMS Star Ratings

• TPS scores increased 2.3 points more in HHVBP agencies than comparison agencies

• TPS scores increased 7.4% over the base-line year

• Mixed results for Medicare spending and utilization• The incentives to change behavior in this first year are weaker because

CY 2016 is a performance year rather than a payment year

• Observed no statistically significant change in unplanned hospitalizations

CMMI First Annual Report on HHVBP (Cont.)

• Mixed findings on effects for OASIS-based measures• Observed improvements in the four functional measure• No difference changes in the other three OASIS quality outcomes• Noted improvements in three OASIS process measures

• No evidence of HHVBP impact on patient experience measures• Patient experience has been stable over time• No differential changes between CY 2015 to 2016

• Early changes in HHA operations were relatively focused and similar to ongoing activities• Agencies did not necessarily shift strategies in response to HHVBP since

quality improvement efforts for CMS Star Ratings and Public reporting of HHC were already underway

CMMI First Annual Report on HHVBP (Cont.)

CMMI First Annual Report on HHVBP (Cont.)

Conclusions

• Largest increases in quality scores were among the four OASIS functional improvement outcome measures

• Outcome improvement may be more related to better accuracy in OASIS scoring

• No detectable impact of HHVBP on home health patient outcomes, utilization, or Medicare spending during the first year

• Behavior may change as payment adjustments are known and as the incentives increase over the 5 model years

CMMI Payment and Adjustment Reports –

PY 2017

Source: CMS Final TPS Adjustment Report PY2

Source: CMS Final TPS Adjustment Report PY2

Source: Home Health Compare – Oct 2018 refresh

Source: CMS Final TPS Adjustment Report PY2

Final Rule on HHVBP for PY 2019

Changes in HHVBP since first year

• CY 2018 Final Rule• Change the HHCAHPS to 40 completed surveys versus 20

• Removed Drug Education from measure list starting in CY 2018 (third performance year)

• Four of the nine states have both small and larger volume cohorts (NE, IA, FL, MA)

• CY 2016 first year performance was not finalized until October 2018 when the final rule was issued

• Uncertainty in knowing how to budget for your bonus/penalty

Measures by NQF Domain (PY 3)

DOMAINS

1) Patient and Caregiver Centered Experience 2) Clinical Quality of Care

3) Communication & Care Coordination 4) Population Health

5) Efficiency and cost reduction 6) Patient Safety

CY 2019 Final Rule - HHVBP

• Removing 5 OASIS measures from the applicable measures• Influenza Immunization Received for Current Flu Season• Pneumococcal Polysaccharide Vaccine Ever Received• Improvement in Ambulation-Locomotion• Improvement in Bed Transferring• Improvement in Bathing

• Adding two new “Composite” measures• Total Normalized Composite Change in Self-Care (6 outcomes)

• Grooming, Bathing, Upper and Lower Dressing, Toileting Hygiene, Eating

• Total Normalized Composite Change in Mobility (3 outcomes)• Toilet Transferring, Bed Transferring, Ambulation

CY 2019 Final Rule – HHVBP (Cont.)

• New Weighting for the measure scores for 90% of the TPS • 35% for the OASIS-based measures (6 outcomes)

• 35% for the Claims-based measures (2 outcomes)• 75% 60-Day Hospitalization, 25% ED use without Hospitalization

• 30% for the HHCAHPS measures (5 outcomes)

• Weighting will be adjusted within each category for measures not meeting the reporting threshold

• The two composites will be weighted as if 3 measures (15 points each)

• Reducing the maximum points for Improvement from 10 points to 9 points (13.5 points for the composite measures)

Re-Weighting Distribution

HHVBP New Scorecard

Changes in TPS with 60 Day ACH Only

Change in Improvement Points

9 x - 0.5

• Reduces the maximum amount of improvement points, from 10 points to 9 points, for PY4 and subsequent performanceyears

• Exception is for the Total Normalized Composite Change in Self-Care and Total Normalized Composite Change in Mobility measures – 13.5 points (90% of 15 points) would be possible

Update Formula:

HHA Performance Period Score – HHA Baseline Period Score

Benchmark – HHA Baseline Period Score

Measures by NQF Domain (PY 4)

DOMAINS

1) Patient and Caregiver Centered Experience 2) Clinical Quality of Care

3) Communication & Care Coordination 4) Population Health

5) Efficiency and cost reduction 6) Patient Safety

TNC Measure Calculation

• The magnitude of possible change depends on the response score of the OASIS Items

Response Options: 4

Max (+) Change: +3

Max (-) Change: -3

Response Options: 7

Max (+) Change: +6

Max (-) Change: -6

TNC Measure Calculation Steps

Computed and normalized at the episode level, then aggregated to the HHA level using the following steps:

Step 1: Compute Absolute Change for each OASIS item by Episode• Subtract discharge response value from SOC/ROC response value for each OASIS

item

Step 2: Compute Normalized Change for each OASIS item by Episode• Divide the absolute change by the maximum positive change possible for each

OASIS item

• Normalized change ranges from -1 to +1 by OASIS Item

Step 3: Sum the Normalized Changes across All OASIS items by Episode• Sum the normalized scores for each OASIS item in each composite measure (TNC

in Self-Care ranges from -6 to +6; TNC in Mobility -3 to +3)

Composite Measure Calculation (cont.)

Step 4: Average the HHA’s Episode-level TNC Values• HHA’s averages range from -6 to +6 for TNC in Self-Care and from -3 to +3

for TNC in Mobility

Step 5: Compute the HHA’s risk-adjusted TNC Measure• Formula: HHARisk Adjusted = HHAObserved + (NationalPredicted – HHAPredicted)

Note: Baseline year for the two composite measures will be CY 2017

TNC– Self-Care: Achievement Threshold (AT) and Benchmarks (BM)

TNC– Mobility: Achievement Thresholds (AT) and Benchmarks (BM)

Composite Measure Postings

• The April 2019 IPRs will contain your agency’s baseline values and state’s Benchmarks and Achievement Thresholds for the two composite measures

• The 2019 Annual Report (PY3) will not include these changes

• Composite Measures and all PY 2019 changes will be included beginning in the July 2019 IPRs

• Technical documentation on risk-adjustment coefficients is expected to be published on HHVBP Connect in mid-2019, including:• Pseudo code

• List of risk factors

• Risk-adjustment coefficients

What is my target?

Wayne Gretzky Quote:

“I skate to where the puck is going to be, not where it has been”

Setting your target

Source: CMS Star Rating Cut Points

Changes in the 9 HHVBP States (Examples)

Source: SHP National Database

• 12 months ending December

Changes in the 9 HHVBP States (Examples)

Source: SHP National Database

• 12 months ending December

Year over Year HHVBP Measures

Source: SHP National Database

HHVBP TPS Scores

Source: SHP National Database

Measure Trends – VBP States TPS Scores

Source: SHP National Database

• Changes in TPS scores Dec 2016 to Dec 2017

Raw Scores Distribution in VBP States

Total Normalized Composite: Mobility

Source: SHP National Data – CY 2018

Raw Scores Distribution in VBP States

Total Normalized Composite: Self Care

Source: SHP National Data – CY 2018

Raw Scores Distribution in Washington

Source: SHP National Data – CY 2018

Average Raw Scores in Washington by Measure

Source: SHP National Data – CY 2018

Achievement Points Comparison: TNC Self-care and Mobility to Ambulation, Bed Transferring and Bathing (max 30 points each)

Source: SHP National Data – CY 2018

Questions?

Chris AttayaVP of Product Strategycattaya@shpdata.com

805-963-9446