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Presentation on theme: "HOSPITAL PAYMENT MODERNIZATION CONNECTICUT’S OPPORTUNITY FOR CHANGE November 2013."— Presentation transcript:


2 MERCER 1 May 4, 2015 1 MERCER Discussion Agenda Project Goals Overview of Conceptual Underpinnings of DRG and APC Suggested Evaluation Criteria Current Project Direction 1

3 MERCER 2 May 4, 2015 2 MERCER Project Goals Design, develop and implement a complete rebuild of both hospital payment systems Implement new prospective payment systems that are ICD-10 capable Systems that are more precise in the recognition of acuity for both IP and OP hospital services Provide payment structures that promote proper delivery of health care in the most appropriate setting Promote more predictable and transparent payment processes for hospitals Revenue neutrality at the hospital level will be a primary goal Over time, migration to more equitable payment systems will likely not result in revenue neutrality at the hospital level. Implement payment methods that can support quality health outcomes and efficiency Create systems that establish a sound financial basis for the changing environment including state and federal policy goals 2

4 MERCER 3 May 4, 2015 Conceptual Underpinnings – Inpatient DRG Systems Each DRG to contain patients with a similar pattern of resource intensity Each DRG to contain patients who are similar from a clinical perspective (i.e., each group should be clinically coherent) DRGs based on routinely collected information from hospital abstract systems A manageable number of DRGs, which encompass all patients seen on an inpatient basis Based on age, principal diagnosis, secondary diagnoses and the surgical procedures performed

5 MERCER 4 May 4, 2015 4 MERCER Conceptual Underpinnings: Some Examples of DRG Pricing 4 Hospital Specific (or Peer Group, or Statewide) Base Rate $4,000 –Knee Replacement / Severity 1 Relative Weight2.0347 ­Hospital Payment$8,139 –Knee Replacement / Severity 4 Relative Weight5.3662 ­Hospital Payment$21,465 –Normal Delivery / Severity 1 / Relative Weight0.4672 ­Hospital Payment$1,869

6 MERCER 5 Conceptual Underpinnings: APR-DRG versus Medicare PDX: 56211 Diverticulitis of colon Proc: 4571Multiple segmental resection of large intestine Case 1Case2Case 3Case 4Description Secondary Diagnoses 56941 5609 56941 5609 4299 4260 56941 5609 4299 4260 5849 Ulcer of anus & rectum Unspecified intestinal obstruction Acute myocarditis Atrioventricular block, complete Acute renal failure, unspecified Medicare DRG APR-DRG 149 wo CC 221 SOI 1 148 w CC 221 SOI 2 148 w CC 221 SOI 3 148 w CC 221 SOI 4 Major small and large bowel Medicare DRG APR-DRG 25,147 25,988 59,519 38,209 59,519 66,597 59,519 130,750 Table 1 Example claims assigned to the DRG systems 5

7 MERCER 6 May 4, 2015 6 MERCER Conceptual Underpinnings – Outpatient APC Systems Ambulatory Payment Classifications (APCs) classify hospital outpatient services (some services, such as Laboratory, are excluded) APCs are conceptually similar and to DRGs in terms of the resources required to provide each service Will support ICD-10 Payment amounts for each APC are based on estimates of the costs associated with providing any of the services assigned to an APC Hospitals continue line item billing using HCPCS/CPT codes and claims administrator receives the claims and applies the appropriate APC payment rates to the HCPCS codes 6

8 MERCER 77 Conceptual Underpinnings: Some Examples of Fee Schedule APCs APCGroup Title Relative Weight Payment Rate 0006Level I Incision & Drainage1.4194$99.38 0008Level III Incision and Drainage20.5466$1,438.59 0041Level I Arthroscopy29.6307$2,074.62 0048Level I Arthroplasty or Implantation with Prosthesis60.6006$4,243.01 0083 Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity65.9825$4,619.83 0108 Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes424.7747$29,741.03 0227Implantation of Drug Infusion Device192.8554$13,502.96 0341Skin Tests0.0814$5.70 0604Level 1 Hospital Clinic Visits0.7682$53.79 0608Level 5 Hospital Clinic Visits2.5210$176.51 0609Level 1 Type A Emergency Visits0.7174$50.23 0630Level 5 Type B Emergency Visits3.7599$263.25

9 MERCER 8 May 4, 2015 8 MERCER Suggested Evaluation Criteria Systems should: –Align payments to the services provided, including differences in acuity –Enable Incentives to provide efficient care in the most appropriate settings –Enhance payment predictability for providers and the State –Maintain access to high quality services –Provide transparent methodologies that are easy to understand and replicate –Be designed to be periodically updated –Accommodate future models and policies, including shared savings, health neighborhoods, incentive pools and episode bundling In the end, systems should promote high value, quality-driven health care services

10 MERCER 9 May 4, 2015 9 MERCER Options Considered Inpatient –Current Method (no change, keep recent Meld approach) –Current Method with Case Mix Adjustment added –DRG Method Outpatient –Current Method (fee schedule and cost to charge ratios) –Fee Schedule APC –Enhanced APG 9 MERCER

11 10 May 4, 2015 10 MERCER Project Direction: Move to DRG and APC Models Incentives clear and aligned –Acuity considered Better able to link to policy initiatives –Can adjust payment levels easily (i.e. <100% to develop incentive pool) –Able to implement P4P Multi-payer initiatives possible Easier to administer for state and hospitals Easier to update Stakeholders are supportive 10

12 Services provided by Mercer Health & Benefits LLC.


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