9. CJR - Rogers. … · ADVANCED PAYMENT MODELS: CJR Eric. M. Rogers MEd.RT(R) Managing Consultant...

4/9/2016

1

experience support //

CPAs & ADVISORS

ADVANCED PAYMENT MODELS: CJR

Eric. M. Rogers MEd. RT(R)

Managing Consultant

2 // experience support

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50

60

70

80

90

100

2011 2015 2016 2018

FFS APMs

HHS goal of 30% of traditional FFS Medicare payments through Advanced

Payment Models (APMs) by the end of 2016 and 50% by the end of 2018

THE CHANGING HEALTH CARE MARKET

The changing health care market

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2

CMMI INNOVATION MODELS

Accountable

Care

BPCI Primary Care

Transition

Medicaid and

CHIP

Acceleration

Models

Speed Adoption

of Best Practices

ACOs Model 1 Advanced Primary

Care Initiative

Reduce Avoidable

Hospitalizations

State Innovation

Models

Beneficiary

Engagement Model

Advanced Payment

ACOs

Model 2 Comprehensive

Primary Care

Initiative

Financial Alignment

Incentive for

Medicare and

Medicaid

Frontier

Community Health

Integration

Community Based

Care Transitions

ACO Investment

Model

Model 3 FQHC Advanced

Primary Care

Practice

Strong Start for

Mothers and

Newborns

Health Care

Innovation Rounds

Health Care Action

and Learning

Network

Next Generation

ACO

Model 4 Graduate Nurse

Education

Medicaid

Prevention of

Chronic Diseases

Health Plan

Innovation Initiative

Innovative Advisors

Program

Pioneer ACO Transforming

Clinical Practice

Medicaid

Emergency

Psychiatric

Demonstration

Million Hearts


The changing health care market

CJR


Bundled Payment Popularity

Source: CMMI Website

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100

200

300

400

500

600

700

800

900

1000

Participants in CMMI Payment Models

4/9/2016

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2013 BPCI Bundled Payments for Care Improvement


Bundled Payment

Model 2

Retrospective acute care

hospital stay + post-acute

care

Model 1

Retrospective acute care

hospital stay

Model 3

Retrospective Post-acute

care

Model 4

Acute-care hospital stay

48 episodes

2 phases

MSA SELECTION

67MSAs

67MSAs

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4/9/2016

4

7

Arkansas Hospitals located in selected CJR MSAs

• CHI St. Vincent Hospital

• National Park Medical Center

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• From 67 MSAs to ALL MSAs

• From hips and knees to:• COPD

• CHF

• AMI

• Pneumonia

PREPARING FOR BUNDLED PAYMENTS

4/9/2016

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9

-$11

$35

$71

$120$127

-$200

-$150

-$100

-$50

$0

$50

$100

$150

Hospital Repayments

Medicare Gainsharing

Net Medicare Impact

In M

illio

ns

CJR makes cents to CMS

2016 2017 2018 2019 2020

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PREPARING FOR BUNDLED PAYMENTS

4/9/2016

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42 CFR PART 510 [CMS-5516-P]

• 60-day public commenting period on proposal ended Sept 8th

• Numerous comments

• Effective April 1, 2016

• Key Changes� 2% to 3% discount

� New targets for fractures

� 67 MSAs

� 3 month delay

� Stop loss reduced

� Quality measures

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Episodes are triggered by hospitalizations of eligible Medicare

FFS beneficiaries discharged with diagnoses:� MS-DRG 469: Major joint replacement or reattachment of lower extremity

with major complications or comorbidities

� MS-DRG 470: Major joint replacement or reattachment of lower extremity

without major complications or comorbidities

Episodes include:� Hospitalization and 90 days post-discharge

� All Part A and Part B services, with the

exception of certain excluded services that

are clinically unrelated to the episode

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Episode definition: General

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EPISODE DEFINITION: SERVICESIncluded

• Physician services

• IP hospitalization (including readmissions)

• IP Psych Facility

• LTCH

• IRF

• SNF

• Home Health

• Hospital OP services

• Independent OP therapy

• Clinical lab

• DME

• Part B drugs

• Hospice

Excluded• Acute clinical conditions not arising

from existing episode-related chronic

clinical conditions or complications of

the LEJR surgery

• Chronic conditions that are generally

not affected by the LEJR procedure or

post-surgical care

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• Retrospective, two-sided risk model with hospitals

bearing financial responsibility

� Providers and suppliers continue to be paid via Medicare

FFS

� In Year 2, actual episode spending will be compared to

episode target prices

• If in aggregate target prices are greater than spending, hospital

may receive reconciliation payment

• If in aggregate target prices are less than spending, hospitals

would be responsible for making a payment to Medicare

PAYMENT AND PRICING: RISK STRUCTURE

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� CMS intends to establish target prices for each participant

hospital prior to start of each performance period

� Includes 3% discount to serve as Medicare’s savings

� Based on blend of hospital-specific and regional episode

data, transitioning to regional pricing.

� Essentially competing against yourself in the beginning

PAYMENT AND PRICING: TARGET PRICE

2/3 hospital

1/3 regional

Year 1 & 2 1/3 hospital

2/3 regional

Year 3 100%

regional

Year 4 & 5

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$47,928

$52,028 $50,954

$46,189

$51,239 $50,328

$55,448

$47,925 $48,874

$24,858 $27,406

$25,480$23,800

$25,989 $26,345 $27,464

$23,734 $23,425

New England Middle Atlantic East North

Central

West North

Central

South Atlantic East South

Central

West South

Central

Mountain Pacific

DRG 469 DRG 470

REGIONAL HISTORICAL CJR PAYMENTS

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$23,800$22,456 +/- ?

$ Target

$20,000

$21,000

$22,000

$23,000

$24,000

$25,000

$26,000

Regional Average Sample Hospital Target Year 1 & 2

1/3


TARGET PRICE CALCULATION: DRG 470

2/3

Wage Index

DSH

IME


UPSIDE AND DOWNSIDE FINANCIAL MODELING

0-20% Stop Loss

5-20% Stop Gain

$9,330,051 Example Reconciliation Target $7,344,781

35

9To

tal

Ep

iso

de

s

$63,460

$53,516 (2X SD)

$21,338

Episode #

324 of 359

4/9/2016

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Minimum threshold for 2 quality metrics

� Hospital Level Risk Standardized Complication Rate

following elective hip and knee arthroplasty

� HCAHP

� 3 decile improvement

� Voluntary THA/TKA data submission of patient

reported outcomes

PAYMENT AND PRICING: LINK TO QUALITY

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QUALITY POINTS

THA/TKA

Complications

HCAHPS Survey

≥ 90th 10.00 8.00

≥ 80th and < 90th 9.25 7.40

≥ 70th and < 80th 8.50 6.80

≥ 60th and < 70th 7.75 6.20

≥ 50th and < 60th 7.00 5.60

≥ 40th and < 50th 6.25 5.00

≥ 30th and < 40th 5.50 4.40

<30th 0.00 0.00

3 Decile Improvement 1.00 0.80

THA/TKA Voluntary PRO and Limited Risk

Variable Data

Yes 2.00

No 0.00

Total Points

14.1

Poor: < 6.03% discount

Good: 6.0 – 13.22% discount

Excellent: >13.21.5% discount

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• Consistent with applicable law, participating hospitals might

have certain financial arrangements with Collaborators to

support their efforts to improve quality and reduce costs.

• Collaborators may include:

� Physician and non-physician practitioners

� Home health agencies

� SNF

� LTCH

� Physician group practices

� IRF

� Inpatient and Outpatient PTs and OTs

FINANCIAL ARRANGEMENTS: GAINSHARING

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• CJR Collaborators may share in both upside and downside risk associated

with participating in the program

• CJR requires signed written agreements with the Collaborators and (if

applicable) also agents of the CJR Collaborators

� Collaborator Agreement

� Distribution Agreement

• CJR regulations set forth a number of regulatory requirements – be

mindful of these requirements when establishing the program and

drafting the documents/agreements

• Compliance with the program requirements is necessary to be afforded

protection under the fraud and abuse waivers

FINANCIAL ARRANGEMENTS: GAINSHARING

4/9/2016

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ALIGNMENT PAYMENTS

Participant Hospitals may include the following in a sharing arrangement (and nothing else):

� Reconciliation Payments: payment from CMS to a CJR hospital when the hospital realizes a positive Net Payment Reconciliation Amount (NPRA)

� Internal Cost Savings: measurable verifiable cost savings realized through care redesign activities associated with services furnished to beneficiaries during a CJR episode

� Alignment Payments: payment from a CJR Collaborator to the a participant hospital whereby the Participant Hospital shares downside risk with CJR Collaborators

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CJR SELECTION CRITERIA

Develop written selection criteria for CJR Collaborators� Selection criteria for CJR Collaborators must relate to the quality of care to

be delivered (it can be prospective or retrospective)

� Examples from CMS include:

• Prior complication rates

• Attending weekly care coordination meeting

• Following specified clinical pathways

• Contacting CJR beneficiaries frequently

� Selection criteria cannot be based, directly or indirectly, on the volume or

value of referrals

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Participant hospitals may assign various percentages of two-

sided risk to collaborators.

� CMS would continue to make reconciliation payments and

recoupments solely with the hospital.

� The hospital would be responsible for paying/recouping

from its collaborators.

CMS will limit the hospital’s sharing of risk to 50% of the total

repayment amount to CMS.

Hospitals can’t share more than 25% of the risk with any one CJR

Collaborator

FINANCIAL ARRANGEMENTS: RISK SHARING

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REQUIREMENTS

• Establish Board or other Governing Body oversight of CJR

• Update Compliance Plan to include oversight of CJR

• Maintain current and historical list of CJR Collaborators –

published on participant hospital’s website

• Issue required Beneficiary Notifications (CMS to issue forms)

• Satisfy documentation requirements, E.g.

� Contemporaneous documentation of gainsharing payments

� Compliance requirements

� 10 year record retention

• Set-up process for EFT payments

4/9/2016

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Goal: Develop reporting

mechanisms and monitor

compliance of calculation

Determine specific procedures to

perform related to the

calculation

Monitor performance of

procedures

Identify data anomalies

Share progress with

Collaborators

Develop and implement control

procedures for calculations

Strategy Engaging Collaborators

Goal: Determine entities to

approach as collaborators

Understand Collaborator

Agreements

Satisfy written selection criteria

requirements

Identify specific collaboration

goals

Analyze available information &

data to identify and select

Collaborators

Identify basic financial sharing

methodologies

1 3 42

Goal: Approach potential

Collaborators and finalized

arrangement parameters

CJR Rule Education, Collaborator

Agreements and Parameters of

Agreements

Provide scenario analyses based

on levels of success

Get collaborators comfortable

with data & process

Negotiate terms and parameters

of Agreements

(Financial & Quality)

Identify related alignment

opportunities

Document sharing arrangements

with negotiated parameters

Internal Cost Savings

ProcessOngoing Support

Goal: Determine specific ICS

parameters in Sharing

Arrangements

Identify incentive goals – implant

cost savings, OR Efficiency etc.

Analyze available data for each

goal – Decision Support, EHR

Develop internal cost savings

methodologies in compliance

with CJR

Select Quality Performance

Metrics & analyze potential

outcomes

Development of CJR Collaborator Agreements

Skilled Nursing Facility

� CJR would waive the SNF 3-day rule for coverage of a SNF stay following the anchor hospitalization

beginning in Year 2

� Patients must be transferred to SNFs rated 3-stars or higher

� Beneficiaries must not be discharged prematurely to SNFs

Home Visits

� CJR would waive the “incident to” rule for physician services

� Allows the licensed clinical staff of a physician to furnish a home visit in the patient’s home

� Permitted only for patients who do not qualify for Medicare coverage of home health services

� Maximum of 9 visits using a new HCPCS code

Telehealth

� Waives the geographic site requirement and the originating site requirement to permit visits

originating in the patient’s home or place of residence

� Cannot be a substitute for in-person home health services

� Must be furnished in accordance with all other Medicare coverage and payment criteria

PROGRAM WAIVERS

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� Data will be shared to evaluate practice patterns, redesign care delivery

pathways and improve care coordination.

� Hospitals can request to obtain beneficiary-level Part A and B claims for the

duration of the episode in summary format, raw claims line feeds, or both.

� Data would be available for the hospital’s baseline period and on a quarterly

basis during the performance period.

� Aggregate regional claims data for MS-DRG 469 and 470 would also be shared

� Hospitals must request data in order to receive it

DATA SHARING

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Beneficiary protection

� Providers and suppliers would be required to notify patients of the

payment model.

� Patient’s access to care would not be impacted by the CJR model.• Copays would not change

• Patient provider relationships would be maintained

• Patients retain entitlement to Medicare covered services

Monitoring

� CMS will monitor compliance with the model requirements

� CMS will monitor potential risks• Increasing profitability by delaying care

• Decreasing costs by avoiding medically indicated care

• Avoiding high cost patients

• Compromised quality or outcomes

OTHER ITEMS

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Case Study


GOVERNANCE AND OVERSIGHT

1

Steering Committee

Prehab

Acute

Transitions

PACIT

Finance

4/9/2016

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DATA ANALYTICS

1 2

Patients

Physicians

Post-Acute Providers


DATA ANALYTICS

1 2

Ris

k S

tra

tifi

cati

on

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35

36

4/9/2016

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37


4/9/2016

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4/9/2016

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Home Health

71%Skilled

Nursing

17%

Other

10%

Hospice

2%

DRG 470

Post Acute Utilization


CARE PATHWAY VALUATION

$15,226

$9,213

$2,787

4/9/2016

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43

4/9/2016

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20

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100

120

140

160

0-60 61-65 66-70 71-75 76-80 81-85 85-90 91-95

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Pa

tie

nt

Vo

lum

e b

y A

ge

Me

dic

are

’s E

pis

od

e P

aym

en

ts

SPENDING BY AGE

DRG 470: TOTAL HIP VS PARTIAL HIP


USING DATA TO REDESIGN CARE

4/9/2016

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13%

20%

67%

PROCEDURE DISTRIBUTION: DRG 470

Partial Hip Total Hip Total Knee

$17,266

$31,934


PATIENTS

$16,777


4/9/2016

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MONITORING PROGRESS

1 2 3 4 5

Monthly progress reports

Key metrics dashboard

Data Custodian

Target price calculation

Reconciliation

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PROJECT MANAGEMENT

Kick-off

Data Analytics Review:

Outcomes Compass

Work Groups Data Review

Collaborator

Identification

Work Group Team Meeting

Acute, Transitions, IT

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct

1Q Reporting

Collaborator

Update

Gainshare

Model

Development

Physician

Workshop

Gainshare

Review

Work Group

Team Meeting

Post Acute

2Q Reporting 4Q Reporting 3Q Reporting

Care Pathway RedesignCare Delivery

EnhancementCare Coordination

Progress

Report

Post-Acute

Workshop

Outcomes Compass Data

Analysis and Review

Value Stream

Mapping

THANK YOU

FOR MORE INFORMATION // For a complete list of our offices

and subsidiaries, visit bkd.com or contact:

Eric M. Rogers M.Ed. RT(R) // Managing Consultant

[email protected] // 417.865.8701


9. CJR - Rogers. … · ADVANCED PAYMENT MODELS: CJR Eric. M. Rogers MEd.RT(R) Managing Consultant...

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