CMMI Update Amy Bassano Deputy Director Center for

CMMI Update Amy Bassano, Deputy Director, Center for Medicare and Medicaid Innovation November 8, 2018

The CMS Innovation Center Statute “The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles” Three scenarios for success from Statute: 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking 2

CMS Innovation Center’s range of impact > 18 million > 207, 000 Beneficiaries touched CMS Innovation Center models impact over 18 M beneficiaries 1, 2 in all 50 states Providers participating Over 200, 000 health care providers and provider groups 2 across the nation are participating in CMS Innovation Center programs Includes CMS beneficiaries (i. e. , individuals with coverage through Medicare FFS, Medicaid, both Medicare and Medicaid (as Medicare-Medicaid enrollees), CHIP, and Medicare Advantage) and individuals with private insurance, including in multi-payer models 2 Figures as of September 30, 2016 1 Source: Innovation Center Report to Congress, December 2016 3

The Innovation Center portfolio aligns with broader CMS goals Test alternative payment models § Accountable Care Pay Providers Deliver Care Distribute Information ‒ ACO Investment Model ‒ Pioneer ACO Model ‒ Medicare Shared Savings Program (housed in Center for Medicare) ‒ Comprehensive ESRD Care Initiative ‒ Next Generation ACO § Primary Care Transformation ‒ Comprehensive Primary Care Initiative (CPC) & CPC+ ‒ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration ‒ Independence at Home Demonstration ‒ Graduate Nurse Education Demonstration ‒ Home Health Value Based Purchasing ‒ Medicare Choices ‒ Frontier Community Health Integration Project ‒ Medicare Diabetes Prevention Program Expanded Model § Bundled payment models ‒ Bundled Payment for Care Improvement Models 1 -4 ‒ BPCI Advanced ‒ Oncology Care Model ‒ Comprehensive Care for Joint Replacement § Initiatives Focused on the Medicaid Population ‒ Medicaid Incentives for Prevention of Chronic Diseases ‒ Strong Start Initiative ‒ Medicaid Innovation Accelerator Program § Dual Eligible (Medicare-Medicaid Enrollees) ‒ Financial Alignment Initiative ‒ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents § Medicare Advantage (Part C) and Part D ‒ Medicare Advantage Value-Based Insurance Design Model ‒ Part D Enhanced Medication Therapy Management Support providers and states to improve the delivery of care § Learning and Diffusion § State Innovation Models Initiative ‒ Partnership for Patients ‒ SIM Round 1 & SIM Round 2 ‒ Transforming Clinical Practice ‒ Maryland All-Payer Model ‒ Pennsylvania Rural Health Model § Health Care Innovation Awards ‒ Vermont All-Payer ACO Model § Accountable Health Communities § Million Hearts Cardiovascular Risk Reduction Model Increase information available for effective informed decision-making by consumers and providers § Information to providers in CMMI models § Shared decision-making required by many models 4

Innovation Center all-inclusive portfolio • • • • • • • • ACO Investment Model Accountable Health Communities Model Advance Payment ACO Model Advanced Primary Care Initiatives Bundled Payments for Care Improvement Models 1 -4 Bundled Payments for Care Improvement (BPCI) Advanced Cardiac Rehabilitation (CR) Incentive Payment Model Community-based Care Transitions Program Comprehensive Care for Joint Replacement Model Comprehensive ESRD Care Model Comprehensive Primary Care Initiative Comprehensive Primary Care Plus + Round 2 Financial Alignment Initiative for Medicare-Medicaid Enrollees FQHC Advanced Primary Care Practice Demonstration Frontier Community Health Integration Project Demonstration Graduate Nurse Education Demonstration Health Care Innovation Awards: Round 1, Round 2 Health Plan Innovation Initiatives Home Health Value-Based Purchasing Model Independence at Home Demonstration Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents: Phase Two Innovation Advisors Program Maryland All-Payer Model Maryland Total Cost of Care Model Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for the Prevention of Chronic Diseases Model Medicaid Innovation Accelerator Program Medicare Acute Care Episode (ACE) Demonstration Medicare Advantage Value-Based Insurance Design Model Medicare Choices Model • • • • • • • Medicare Coordinated Care Demonstration Medicare Diabetes Prevention Program Expanded Model Medicare Health Care Quality Demonstration Medicare Hospital Gainsharing Demonstration Medicare Imaging Demonstration Medicare Intravenous Immune Globulin (IVIG) Demonstration Million Hearts: Cardiovascular Disease Risk Reduction Model Multi-Payer Advanced Primary Care Practice Next Generation ACO Model Nursing Home Value-Based Purchasing Demonstration Oncology Care Model Part D Enhanced Medication Therapy Management Model Partnership for Patients Pennsylvania Rural Health Model Physician Group Practice Transition Demonstration Physician Hospital Collaboration Demonstration Pioneer ACO Model Private, For-Profit Demonstration Project for the Program of All-Inclusive Care for the Elderly (PACE) Regional Budget Payment Concept Rural Community Hospital Demonstration Specialty Practitioner Payment Model Opportunities State Innovation Models Initiatives Strong Start for Mothers and Newborns Initiatives Transforming Clinical Practice Initiative Vermont All-Payer Model 5

New Direction - CMS Innovation Center Request for Information (RFI) The RFI seeks broad input related to a new direction for the CMS Innovation Center that will promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, and improve outcomes. The administration plans to launch models in several focus areas: • • Expanded Opportunities for Participation in Advanced APMs Consumer-Directed Care & Market-Based Innovation Models Physician Specialty Models • Physician-Focused Payment Model Technical Advisory Committee (PTAC) Recommended Models Prescription Drug Models Medicare Advantage (MA) Innovation Models State-Based and Local Innovation, including Medicaid-focused Models Mental and Behavioral Health Models Program Integrity Guiding Principles • Choice and competition in the marketplace • Provider choice and incentives • Patient-centered care • Benefit design and price transparency • Transparent model design and evaluation • Small scale testing 6

Comprehensive Primary Care Plus (CPC+) CMS’s largest-ever initiative to transform how primary care is delivered and paid for in America GOALS PARTICIPANTS AND PARTNERS 1. Strengthen primary care through multi-payer payment reform and care delivery transformation. • Advanced primary care practices in two rounds: 2. Support clinicians to provide comprehensive care that meets the needs of all patients. • Two tracks to accommodate diversity of practices 3. Improve quality, access, and efficiency of care. • Health IT vendors partner with CMS and Track 2 practices • Round 1: 2, 893 practices in 14 regions • Round 2: Up to 1, 000 practices in 4 regions • 62 public and private payers in CPC+ regions • 5 year model: 2017 -2021; 2018 -2022 CARE TRANSFORMATION FUNCTIONS PAYMENT REDESIGN COMPONENTS Access and continuity PBPM risk-adjusted care management fees Care management Performance-based incentive payments for quality, experience, and utilization measures that drive total cost of care Comprehensiveness and coordination Patient and caregiver engagement Planned care and population health For Track 2, hybrid of reduced fee-for-service payments and up-front “Comprehensive Primary Care Payment” to offer flexibility in delivering care outside traditional office visits 7

Pennsylvania Rural Health Model aims to help rural hospitals improve quality and address community health needs Alternative payment model, which began on January 12, 2017, in collaboration with Pennsylvania and focused on improving the cost and quality of care delivered at hospitals in rural Pennsylvania. Key Features: • Hospital Global Budgets: Pennsylvania will set the all-payer global budget for each participating rural hospital for inpatient and outpatient services • Hospital Care Delivery Transformation: Hospitals will plan changes to redesign care, including investing in quality and tailoring services to their communities • Funding for Model: $25 million made available to help Pennsylvania begin Model implementation Pennsylvania Commits to Achieving the Following Rural Targets: Financial: $35 million in Medicare hospital savings; all-payer target of no more than 3. 38% in annual hospital spending growth. Scale: At least 6 rural hospitals will participate during Performance Year 1 (2018), 18 rural hospitals during Performance Year 2 (2019), and 30 rural hospitals during each of Performance Years 3 through 6 (2020 -2023). Population Health, Access & Quality: 1) increase access to primary and specialty care; 2) reduce rural health disparities through improved chronic disease management; and 3) decrease deaths from substance use. 8

Maryland Total Cost of Care Model New Model in Maryland Covering Full Continuum of Care Components of Maryland Total Cost of Care Model Benefits of TCOC Model ü Adds new providers and settings into care transformation effort Hospital Global Budgets Population-based payments for Maryland hospitals; Continuation of policy from Maryland All-Payer Model Hospital only Care Redesign Program Gainsharing between hospitals, hospital-based specialists, non-hospital providers Inpatient and outpatient settings Maryland Comprehensive Primary Care Program Financial support for primary care providers performing care management for high-risk patients ü Links disparate providers to create more patientcentered care ü Aligns incentives across providers to reduce hospitalizations and total cost of care Primary care and community settings Performance Period begins January 1, 2019 and continues through 2026 9

Bundled Payment for Care Improvement Advanced (BPCI Advanced) BPCI Advanced is a voluntary bundled payment model that qualifies as an Advanced Alternative Payment Model (Advanced APM) with payment tied to performance on quality measures. • Runs October 1, 2018 through December 31, 2023 • Single payment and risk track, with a 90 -day episode period – 29 Inpatient Clinical Episodes – 3 Outpatient Clinical Episodes – Preliminary Target Prices provided prior to the start of the Performance Period Who can participate? – Convener Participants (Medicare enrolled or non-Medicare enrolled providers) – Non-Convener Participants (Medicare enrolled providers only) Who are the Episode Initiators? – Acute Care Hospitals (ACHs) – Physician Group Practices (PGPs) 10

Key Differences: BPCI vs. BPCI Advanced 48 Inpatient (IP) Clinical Episodes 29 IP and 3 OP Clinical Episodes Not an Advanced APM since lacking CEHRT requirement and quality not tied to payment Model is an Advanced APM No quality measures required for payment purposes Quality measures are reportable and performance on these measures will be tied to payment Excludes cost of care associated with services according to 13 unique exclusion listings of “unrelated” care Limited exclusions; Excludes the Part A & B costs associated with ACH readmissions qualifying based on a limited set of MS-DRGs Model 3 includes PAC providers triggering episodes in the post-discharge period No equivalent for Model 3; design is similar to Model 2 with PGPs and ACHs as EIs; PAC Providers, and other Medicare-enrolled, as well as non-Medicare-enrolled entities can participate as Convener Participants Risk corridor of 20% of spending above the upper limit of the selected risk track One risk track Risk is capped at +/-20% Target Prices provided at reconciliation Preliminary Target Prices provided prospectively, before the start of each Model Year 11

Accountable Health Communities Model addresses health-related social needs Key Innovations • Systematic screening of all Medicare and Medicaid beneficiaries to identify unmet health-related social needs • Tests the effectiveness of referrals and community services navigation on total cost of care using a rigorous mixed method evaluative approach Model Tracks • Partner alignment at the community level and implementation of a communitywide quality improvement approach to address beneficiary needs Assistance Track • Bridge Organizations in this track provide community service navigation services to assist high-risk beneficiaries with accessing services to address health-related social needs Alignment Track • Bridge Organizations in this track encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries 12

Integrated Care for Kids (In. CK) Model The In. CK Model is a child-centered local service delivery and state payment model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and CHIP, especially those with or at-risk for developing significant health needs. Goals: 1 Improving performance on priority measures of child health 2 Reducing avoidable inpatient stays and out-of-home placements 3 Creation of sustainable Alternative Payment Models (APMs) Up to 8 cooperative agreement awards anticipated Summer 2019 13

Medicare Diabetes Prevention Program (DPP) Expanded Model MDPP is a structured behavioral intervention with the goal of preventing progression to type 2 diabetes in individuals with an indication of pre-diabetes. Timeline: 2012 – CMS Innovation Center awarded Health Care Innovation Award to The Young Men’s Christian Association of the USA (YMCA) to test the DPP in >7, 000 Medicare beneficiaries with pre-diabetes across 17 sites nationwide. 2016 – DPP announced as the first ever prevention model to meet statutory criteria for expansion. The Secretary determined that DPP: • Improves quality of care beneficiaries lost about five percent body weight • Certified by the Office of the Actuary as cost-saving projected net savings of $186 Million to the Medicare Program over a 10 year period • Does not alter the coverage or provision of benefits 2016 - 2017 – National expansion established through rulemaking, with policies to create a new supplier class finalized in CY 2017 PFS Final Rule and additional policies related to performance-based payment proposed in CY 2018 PFS Proposed Rule. April 2018 – National availability of MDPP set of services to Medicare beneficiaries. 14

Innovation Center – 2018 Looking Forward We are focused on: Ø Implementation of Models Ø Monitoring & Optimization of Results Ø Evaluation and Scaling Ø Integrating Innovation across CMS Ø Portfolio analysis and launch new models to round out portfolio 15

Thank you! Questions? 16