SOLICITATION NOTICE
R -- GROUPER EPISODE FOR MEDICARE
- Notice Date
- 5/10/2010
- Notice Type
- Presolicitation
- NAICS
- 541511
— Custom Computer Programming Services
- Contracting Office
- Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Acquisition and Grants Management, 7500 Security Blvd., C2-21-15, Baltimore, Maryland, 21244-1850
- ZIP Code
- 21244-1850
- Solicitation Number
- RFP-CMS-2010-DRCG02
- Point of Contact
- Joseph Feibel, Phone: 410-786-8261, Evelyn Dixon, Phone: 410-786-1561
- E-Mail Address
-
joseph.feibel@cms.hhs.gov, Evelyn.Dixon@cms.hhs.gov
(joseph.feibel@cms.hhs.gov, Evelyn.Dixon@cms.hhs.gov)
- Small Business Set-Aside
- N/A
- Description
- CMS intends to award one or more contracts for Grouper Episode for Medicine. This is a full and open competition. Potential offerors are hereby advised that their accounting system must be adequate for determining costs applicable to the contract. The North American Industrial Classification System (NAICS) code is 541511. This is not an invitation for bid, request for quote or other solicitation and in no way obligates the Government to award a contract(s). BACKGROUND: Policy makers have expressed concerns that the current Medicare payment system includes incentives that encourage physicians to overuse some services and underuse others, pays physicians for care irrespective of their level of resource use, and offers higher revenues to physicians who furnish more services, regardless of whether they add value (MedPAC 2008). To remedy these concerns, the concept of value based purchasing (VBP) has been introduced into the policy arena. The goal of a VBP program is to provide information to providers to encourage more efficiency and to find ways to reward physicians financially for efficient use of resources and providing high quality care. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires the Department of Health and Human Services (DHHS) to develop a plan that will transition Medicare payments into a VBP program for physician and other professional services. Such a program will pay based on efficiency and the quality of services provided. The Act also requires DHHS to disseminate confidential feedback reports to physicians using episode groupers and/or per capita cost measures. The Patient Protection and Affordable Care Act (2010) has the following provision in Sec 3003 IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM: The Secretary shall develop an episode grouper that combines separate but clinically related items and services into an episode of care for an individual, as appropriate. The episode grouper shall be developed by not later than January 1, 2012. The episode grouper is also integral to the technology required to fulfill Sec. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN FEE SCHEDULE. This section requires the Secretary to establish a payment modifier that provides for differential payments to a physician or a group of physicians for all services furnished under the Medicare Physician Fee Schedule (MPFS). The differential payments would be made based on the quality of care furnished compared to cost. CMS has been investigating techniques that can help identify higher cost practice patterns among physicians. One technique is to compare resource use at the episode of care level. Episodes of care represent a group of healthcare services (claims) for a health condition (e.g., hip fracture, diabetes) over a defined period of time for which a physician can be held responsible. Episode groupers are software programs that organize claims data into a set of clinically coherent episodes, usually linked by diagnoses. Episode grouping software requires users to specify the input parameters for a given set of outputs or data points produced by the software. The user determines the types of claims data that will be grouped, the time frames for which the data are collected, the various software profile settings, the physician attribution and benchmarking algorithms, and the information and resource metrics that will be provided to clinicians, among other decisions. Because of this flexibility and the substantial user discretion, no one correct episode grouping method exists. In the two commercial grouping software products evaluated by Acumen, LLC under contract to CMS, episode types are characterized as chronic, acute, or preventive care. Chronic condition episodes typically are administratively defined for episode grouping purposes as having a 12-month duration, usually a calendar year. Acute episodes have no administratively-imposed time limits. Acute and preventive care episodes are generally much shorter in duration than chronic episodes, and are considered complete or "closed" when there is no activity within a given period. For example, if 90 days is set as the "clean period" for an episode related to hip fracture, and no claims listing a diagnosis of hip fracture are encountered 90 days after a claim in which hip fracture is diagnosed or treated, then the episode is deemed complete. Only certain claim types can initiate or open an episode. Physician Part B evaluation and management claims or surgery claims, an inpatient hospitalization, or a skilled nursing facility stay can start an episode. Ancillary claims and durable medical equipment claims cannot start an episode in either existing episode grouper, while home health claims and hospice claims may start an episode in one of the episode groupers studied. Since a person can be treated for more than one condition at the same time, episodes may be open simultaneously for different conditions. The first CMS report on episode groupers by Acumen, LLC, entitled "Evaluating the Functionality of the Symmetry ETG and Medstat MEG Software in Forming Episodes of Care Using Medicare Data," concludes that 1) the grouping algorithms do not emulate physician practice patterns common in the Medicare system, 2) inpatient physician services often do not group with the associated hospital stays, and 3) there is considerable variation in costs within episodes and within episode types." This large variation in episode costs "...suggests the need to develop models of risk or severity adjustment applicable for Medicare populations prior to being able to use the episodes software for profiling Medicare providers". A second CMS report by Acumen, entitled "Prototype Medicare Resource Utilization Report Based on Episode Groupers," discusses practical aspects of implementing resource utilization reports using episode groupers. The user shall determine how to apportion costs into episodes, risk adjust costs if necessary, assign physicians to those episodes, and define relevant peer groups for the purpose of comparing physicians' costs to each other. Empirical analysis is performed on the number of episodes required for valid comparisons among physicians). Determination and use of options is determined by the user. On November 10, 2009, CMS hosted a public listening session on the design of a public domain episode grouper. This listening session solicited stakeholder comments on the range of issues in the analysis of the applicability of currently available tools to identify discrete episodes of care for Medicare beneficiaries. The url announcing the listening session is located at: http://edocket.access.gpo.gov/2009/pdf/E9-22959.pdf. The background information for the Session, including a white paper and PowerPoint slides can be found at: http://www.cms.hhs.gov/PhysicianFeeSched/downloads/Listening_Session_Slides_2009-11-10_508_compliant.pdf. This procurement continues the process of developing a public use episode grouping software. DESCRIPTION OF REQUIREMENTS: Approach A The goal of Approach A is to modify an existing episode grouping software product for use in the Medicare program. The grouping processes and logic shall be readily understandable, transparent, and comprehensible to multiple stakeholders, including physicians, policy makers, and administrators. The logic shall be valid and reliable, and have a reasonable number of homogenous cost groupings (not thousands). Conceptually, episode grouping is comprised of three sub-systems or modules: clinical logic, episode construction logic, and the risk adjustment method. Clinical logic refers to the basic framework for clustering, the rationale for grouping of condition codes, grouping algorithms, co-morbidities, hierarchy of grouping codes, acute exacerbations, signs and symptom diagnosis, disease interactions, and possibly severity levels (depending on the structure of the system). Episode construction logic establishes the processes and rules by which claims are grouped using the clinical logic. Each of these subsystems can stand on its own, or be integrated with the other components into a software program that groups claims into episodes. Approach A is organized by these sub-systems. This procurement is only for episode grouping software and its components. Elements of a profiling system (attribution rules, benchmarking, standardized costs, etc.) may be considered in the design of data items that will be part of the grouper software's output design. Use of these elements will be determined by the vendor in collaboration with CMS. Approach B The goal of Approach B is to construct a new comprehensive public domain episode grouper. The grouping processes and logic shall be readily understandable, transparent, and comprehensible to the intended audience of physicians, policy makers, and health care administrators. It shall be valid and reliable, and have a reasonable number of homogenous episode groupings (not thousands). Conceptually, episode grouping is comprised of three sub-systems or modules: clinical logic, episode construction logic, and the risk adjustment method. Clinical logic refers to the basic framework for clustering, the rationale for grouping of condition codes, grouping algorithms, co-morbidities, hierarchy of grouping codes, acute exacerbations, signs and symptom diagnosis, interactions, and possibly severity levels (depending on the structure of the system). Episode construction logic establishes the processes and rules by which claims are grouped using the clinical logic. Each of these subsystems can stand on its own, or be integrated with the other components into a software program that groups claims into episodes. Approach B is organized by these components. This procurement is for only episode grouping software and its components. Elements of a profiling system, e.g., attribution rules, benchmarking, standardized costs, etc., may be considered in the design of data items that will be part of the grouper software's output (with input from CMS). The Government anticipates awarding Cost-Plus-Fixed-Fee (CPFF) contract(s). However, the Government reserves the right to negotiate different type of Contract(s). The Period of Performance is estimated as follows: APPROACH A It is anticipated that the base period may be awarded to more than one contractor. The period of performance for the base period is 15 months; the period of performance for the Option, if exercised, is 24 months. APPROACH B It is anticipated that the base period will be awarded to more than one contractor. The period of performance for the base period will not exceed 15 months; and the period of performance for the option period, if exercised, will not exceed 48 months. This announcement is not a request for proposal (RFP). CMS anticipates release of the Request for Proposal in late May or early June 2010 and it will be made available electronically at http://www.fbo.gov.
- Web Link
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(https://www.fbo.gov/spg/HHS/HCFA/AGG/RFP-CMS-2010-DRCG02/listing.html)
- Record
- SN02145466-W 20100512/100510235034-561c62af445010b2160cf8008f0e067e (fbodaily.com)
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