ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APR-DRG Payment System Implementation February 6, 2014 -...

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

APR-DRG Payment System Implementation

February 6, 2014 - DRAFT

TABLE OF CONTENTS

Section 1 » Overview of DRG Payment Model

Section 2 » AHCCCS Guiding Principles and Considerations

Section 3 » New DRG System Pricing Formulas

Section 5 » DRG Pricing Model

Section 6 » Policy Issues

Section 7 » Hemophilia and Blood Clotting Factors

Section 8 » Documentation and Coding Improvement

OVERVIEW OF DRG PAYMENT MODELS

OVERVIEW OF DRG MODELS

» DRG models generally pay a fixed amount, which is known in advance, on a “per discharge” basis, and based on the patient’s DRG assignment

» DRG Patient Classifications Systems, or “Groupers”, assign each patient discharge to a DRG, based on the patient’s diagnoses, surgical procedures performed, age, gender, birth weight and discharge status

» Each DRG has a relative weight factor, which recognizes the differences in resource requirements based on patient’s assigned DRG


» Payment is generally determined by multiplying a hospital’s “base rate” by the assigned DRG’s relative weight factor

» An “outlier” payment provision is typically incorporated to provide additional payments where the base DRG amount is not appropriate – generally cases with extraordinarily high costs

» Payment models are also commonly modified to affect payment for specialty services or providers, including behavioral health, rehabilitation, neonatal, pediatric and others


» There are two DRG grouper models that are broadly used by public and commercial payers for classifying patients into DRGs› All Patient Refined DRGs (APR-DRGs)› Medicare Severity DRGs (MS-DRGs)

» While a number of state Medicaid programs rely on MS-DRGs for DRG payment models, the APR-DRG groper is considered to be a superior model for payments targeted to the Medicaid (i.e., non-aged) population

Source: Quinn, K, Courts, C. Sound Practices in Medicaid Payment for Hospital Care. CHCS: November 2010, updated with current information by Navigant.

DescriptionMS-DRGs

(CMS - Maintained by 3M)APR-DRGs

(3M and NACHRI)

Intended PopulationMedicare (age 65+ or under age 65 with disability)

All patient (based on the Nationwide Inpatient Sample)

Overall approach and treatment of complications and comorbidities (CCs)

Intended for use in Medicare Population. Includes 335 base DRGs, initially separated by severity into “no CC”, “with CC” or “with major CC”. Low volume DRGs were then combined.

Structure unrelated to Medicare. Includes 314 base DRGs, each with four severity levels. The is no CC or major CC list; instead, severity depends on the number and interaction of CCs.

Number of DRGs 746 1,256

Newborn DRGs 7 DRGs, no use of birth weight28 base DRGs, each with four levels of severity (total 112)

OVERVIEW OF DRG GROUPERS

DescriptionMS-DRGs

(CMS - Maintained by 3M)APR-DRGs

(3M and NACHRI)

Psychiatric DRGs9 DRGs; most stays group to “psychoses”

24 DRGs, each with four levels of severity (total 96)

Payment Use by Medicaid (or Moving Toward Use)

KS, MI, NC, NH, NM, OK, OR, SD, WI, WV

AZ, CA, CO, FL, IL, KY, MA, MD, MN, MS, MT, ND, NE, NY, OH, PA, RI, SC, TX, WA

Payment use by other payers

Commercial plan use Commercial plan use

Other users Medicare, hospitalsHospitals, AHRQ, MedPAC, JCAHO, various state “report cards”

Uses in measuring hospital quality

Used as a risk adjustor in measuring readmissions. Used to reduce payment for hospital-acquired conditions.

Used as risk adjustor in measuring mortality, readmissions, complications. Can also be used to reduce payment for hospital-acquired conditions.

Source: Quinn, K, Courts, C. Sound Practices in Medicaid Payment for Hospital Care. CHCS: November 2010, updated with current information by Navigant.


CMS-DRGsAP or Tricare DRGs

APR-DRGs (Using or Moving Toward Use) MS-DRGs (Using or Moving Toward Use)

Per Stay/Per Diem/Cost Reimbursement/Other


What Are Other State Medicaid Programs Doing?


Benefits of Migrating

to APR-DRGs

Facilitates Measurement of Potentially Preventable

Readmissions and Complications

Enhances Recognition of Acuity Related to Specialty

Hospitals, Including Children’s and Teaching

Hospitals

Enhances Recognition of Resources Necessary for

High Severity Patients

Reduces Occurrences of Outlier Cases

Incorporates Age into Classification Process –

Critical for Neonatal Cases

Enhances Homogeneityof Classifications – Superior Measurement of Resources

MS-DRGs designed for classification of Medicare patients …

Source: CMS, “Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule,” Federal Register 72:162 (Aug. 22, 2007): 47158

“The MS-DRGs were specifically designed for purposes of Medicare hospital

inpatient services payment…We do not have comprehensive data from non-

Medicare payers to use for this purpose. The Medicare program only provides

health insurance benefits for people over the age of 65 or who are disabled or

suffering from end-stage renal disease. Therefore, newborns, maternity, and

pediatric patients are not well represented in the MedPAR data that we used in

the design of the MS–DRGs. We simply do not have enough data to establish

stable and reliable DRGs and relative weights to address the needs of non-

Medicare payers for pediatric, newborn, and maternity patients. For this reason,

we encourage those who want to use MS-DRGs for patient populations other

than Medicare [to] make the relevant refinements to our system so it better

serves the needs of those patients.”


GUIDING PRINCIPLES AND CONSIDERATIONS FOR DESIGN AND IMPLEMENTATION BY AHCCCS

GUIDING PRINCIPLES AND CONSIDERATIONS

Guiding Principles for Evaluating Options

Cost Effectiveness Is the option aligned with incentives for providing cost effective care?

Access Does the option promote access to quality care, consistent with federal requirements?

Equity Does the option promote equity of payment through appropriate recognition of resource intensity and other factors?

Resource Recognition Does the option recognize measurable differences in resource requirements?

Predictability Does the option provide predictable and transparent payment for providers and the State?

Transparency and Simplicity

Does the option enhance transparency, and contribute to an overall methodology that is easy to understand and replicate?

Quality Does the option promote and reward high value, quality-driven healthcare services?

GUIDING PRINCIPLES AND CONSIDERATIONS

Other Design Considerations

Budget Neutrality Funding is not unlimited – goal for design is to be budget neutral.

Adaptability Does the option promote adaptability for future changes in utilization and the need for regular updates?

Forward Compatibility

Is the option flexible enough to support payment structures in anticipated future service models?

Policy Is the option consistent with State and Federal policy priorities?

NEW DRG SYSTEM

PRICING FORMULAS

NEW DRG SYSTEM PRICING FORMULAS

DRG Base Payment

Outlier Add-on Payment (If applicable)

Claim Payment +=

DRG Base

Payment

DRG Relative Weight

DRG Base Rate

x= x Policy Adjustor

Note: DRG base payment is sometimes reduced on transfer and partial eligibility claims.

DRG base payment formula

Provider DRG

Transition Multiplier

x)(

DRG base rate

» DRG base rates are based on a statewide standardized amount of $5,295.40

» The labor portion of the statewide standardized amount is adjusted by each hospital’s Medicare wage index › Wage index is a factor that represents differences the relative hospital wage level in

the geographic area compared to the national average hospital wage level› Example base rate calculation:

($5,295.40 X 0.696 labor portion X 1.0366 wage index) +($5,295.40 X 0.304 non-labor portion) = 5,430.29 DRG base rate

» High volume “hold harmless” adjustment applied to providers who meet specific Medicaid volume criteria and are projected to incur a loss under the new system› ADD SPECS


DRG relative weights

» DRG relative weight is a factor that represents the average resource requirements for each DRG› DRG relative weight of 1.0 indicates average resource requirements

(relative to all other inpatient services)

» The new system APR-DRG relative weights are based on the “National Weights” calculated annually by 3M using a national dataset 15 million inpatient claims


Example APR-DRG Weight

Low weight DRG 640-1 – Normal newborn 0.0969

Average weight DRG 225-2 – Appendectomy 1.0240

High weight DRG 002-4 – Heart transplant 21.2277

USE OF POLICY ADJUSTORS

Policy adjustor factors» Key Medicaid services targeted for enhanced payment to ensure access

to care» Policy adjustor factors applied to DRG base payments:

› Normal newborn DRGs: 1.55 factor› Neonate DRGs: 1.10 factor› Obstetric DRGs: 1.55 factor› Psychiatric/Rehabilitation DRGs: 1.65 factor› Other pediatric cases (age 18 and under): 1.25 factor

» Policy adjustor values set at levels for each service to achieve same pay-to-cost ratio as statewide average (including allocated static payments)

› Exception: Psychiatric/Rehabilitation policy adjustor set to achieve current system spending

POLICY ADJUSTORS IMPACT

Policy adjustor modeled results

Model Policy Adjuster

(Based on APR-DRG

Assignment and Age) FFY 2011 Cases

APR-DRG Case

Mix Index

Current System

Estimated

Payment-to-

Cost Ratio

Policy Adjustor

Model

Estimated

Payment-to-

Cost Ratio

Estimated

Payment

Change

Percentage

Neonate 3,988 2.509 70.3% 72.7% 3.4%

Normal newborn 42,394 0.123 76.0% 72.9% -4.1%

Obstetrics 49,192 0.399 67.0% 72.5% 8.3%

Psychiatric/Rehabilitation 890 1.046 69.6% 70.8% 1.8%

Other pediatric services 26,474 0.826 65.2% 74.0% 13.6%

Other adult services 74,953 1.123 76.8% 72.0% -6.3%

Inpatient Total 197,891 0.717 72.5% 72.5% 0.0%

Outlier Add-on

Payment (if claim

qualifies)

=Outlier

Threshold

DRG Marginal

Cost Percentage

ClaimCost x-( )

Note: Outlier payments are only applied if claim cost is greater than the outlier threshold.


Outlier add-on payment formula

DRG Base Payment


Claim Payment +=

Provider DRG


x)(

Outlier add-on payment components

» Outlier add-on payment made for extraordinary cost cases where the claim cost exceeds the outlier threshold for a DRG

» Outlier threshold equal to the base DRG payment plus the fixed loss threshold› Provider must incur a “fixed loss” on the claim for costs exceeding the base DRG

payment› Fixed Loss Amount is $5,000 for Critical Access Hospitals (CAH)/small rural

providers and $65,000 for all other providers.

» Outlier add-on payment calculated as the cost exceeding the outlier threshold, multiplied by the DRG marginal cost percentage› DRG marginal cost percentage is 90% for burn DRGs and 80% for all other DRGs


Provider DRG Transition Multiplier =

Documentation and Coding

Improvement Factor

Transition Impact Factor

x

Note: Outlier payments are only applied if claim cost is greater than the outlier threshold.


Transition adjustment factor formula

DRG Base Payment


Claim Payment +=

Provider DRG


x)(

Provider DRG transition multiplier components

» Transition adjustment factor is a temporary (first two years only) provider-specific factor that limits the payment gain or loss under the new system based on the payment simulation model› Year 1 factor limits the gain or loss to 33% of the full estimated gain/loss› Year 2 factor limits the gain or loss to 66% of the full estimated gain/loss

» Documentation and coding improvement factor is a statewide factor that is a preemptive adjustment for an expected 3 percent increase in DRG case mix over “real” case mix increases as a result of improved documentation and coding under the new system› 0.9739 factor in Year 1› Adjustments in future periods may depend on actual trends



TransferDRG Base Payment

=DRG

National Average

Length of Stay

Claim Length of Stay +1

DRG Base Payment

x/( )

» Claim payment where an acute patient is transferred to another hospital is pro-rated based on claim length of stay

» Transfer payment cannot exceed the full DRG base payment

Transfer payment formula

AHCCCS DRG PRICING MODEL


New system DRG payment simulation» DRG pricing model simulates payments under the new DRG system,

including the DRG base payment, outlier payment and policy adjusters, using historical claims data

» Model used to establish what the DRG base rates can be given all other payment methodology parameters, while maintaining budget neutrality

» Model also compares simulated payments under the new system to payments under the current system and estimated provider costs, at the following levels:› Provider level› Service line level› System aggregate


Standardized amount determination» DRG pricing model is based on FFY 2011 Arizona Medicaid FFS claims

and managed care encounter data and Medicare cost report data for in-state providers and critical out-of-state providers

» Funding pool for determination of budget neutrality is based on FFY 2011 model claim/encounter total reported payments, with reductions applied to reflect payment rate/methodology changes since 2011

» DRG base rates “solved for” to be budget neutral to current system payments

› DRG base rates result in aggregate simulated DRG payments that are approximately equal to FFY 2011 aggregate adjusted reported payments

POLICY ISSUES

POLICY ISSUES – ENROLLMENT CHANGE DURING HOSPITAL STAY

» Recipient may change payers during a single hospital stay, while maintaining Medicaid eligibility throughout entire stay

» This may occur under a variety of scenarios including

› Enrollment change from fee-for-service to managed care plan› Enrollment change from managed care plan to fee-for-service› Enrollment change between managed care plans within the same program› Enrollment change between managed care plans in different programs, for

example moving from an Acute MCO to the Arizona Long Term Care System (ALTCS)

» Services paid via DRG method will be paid by the payer to which the recipient is enrolled at the date of discharge

» Providers to submit a claim to the appropriate payer

POLICY ISSUES – MEDICARE PART A BENEFITS EXHAUSTED

» In the event recipient exhausts Medicare Part A benefits during a single hospital stay, providers must submit a second claim for the Medicaid covered portion of the stay

» A full DRG payment will be paid for the Medicaid claim

POLICY ISSUES – ADMINISTRATIVE DAYS

» AHCCCS may offer reimbursement for Medicaid recipients occupying a bed while not in need of care

› These days are referred to as administrative days

» Administrative days must be prior authorized by AHCCCS

» Administrative days will be reimbursed using a negotiated per diem rate

» Reimbursement for administrative days will be separate from DRG reimbursement for acute care services and provider must bill such days on a separate claim

POLICY ISSUES – INTERIM CLAIMS

» A recipient may be in the hospital for an extended period of time

» If patient stay exceeds a 29 day period, hospitals may submit interim claims related to the patient stay in increments of 30 days

» Interim claims will be reimbursed under a per diem rate of $500 per day

» Hospitals must submit a final claim associated with the patient stay upon the patient’s discharge – all previously submitted interim claims will be voided and final claim will be paid

POLICY ISSUES – RECIPIENT GAINS ELIGIBILITY AFTER ADMISSION

» A recipient may be ineligible for Medicaid upon admission, however, may become eligible for Medicaid during the hospital stay

» Providers will be reimbursed for the Medicaid covered days of the hospital stay

› The DRG payment designed to cover the full hospital will be prorated based on the number of Medicaid covered days

› This prorated payment to providers will not exceed the full DRG payment

» Only claims with dates of service where the recipient is an eligible member will be accepted

POLICY ISSUES – RECIPIENT LOSES ELIGIBILITY PRIOR TO DISCHARGE

» A recipient may be eligible for Medicaid upon admission, however, may lose eligibility for Medicaid prior to being discharged

» Providers will be reimbursed for the Medicaid covered days of the hospital stay

› The DRG payment designed to cover the full hospital will be prorated based on the number of Medicaid covered days

› This prorated payment to providers will not exceed the full DRG payment

» Only claims with dates of service where the recipient is an eligible member will be accepted

POLICY ISSUES – SAME DAY ADMISSION AND DISCHARGE

» A recipient may be admitted and discharged on the same day

» Inpatient claims with a date of admission matching the date of the discharge will be paid under the reimbursement policy that is currently in place for AHCCCS, with one exception.

» Maternity and nursery claims will be reimbursed under the AHCCCS Outpatient Hospital Fees Schedule Methodology (OPFS)

POLICY ISSUES – HEALTH CARE ACQUIRED CONDITIONS (HCAC’S)

» For claims paid via DRG methodology, AHCCCS will utilize DRG assignment to determine payment reductions in cases of health care acquired conditions

» A present on admission (POA) indicator will continue to be required on all inpatient claims as the HCAC payment reduction policy only applies if the HCAC condition(s) were acquired in the hospital after admission

» Under the DRG methodology, two DRGs will be assigned to every claim (“pre-HCAC” and “post-HCAC”). The DRG will the lower relative weight will be used to price the claim.

POLICY ISSUES – READMISSION POLICY

» A recipient may be readmitted to a hospital after receiving a service or treatment

» For claims paid under DRG methodology, the Administration will identify certain readmission cases and conduct a medical review to determine if the readmission was preventable by the hospital

» The following criteria will prompt a medical review

› Recipient is readmitted to the same hospital within 72 hours, and› The base DRG assignment on the readmission claim must match

the base DRG assignment on the initial claim, and › The readmission claim has not been prior authorized

POLICY ISSUES – READMISSION POLICY

» Claims which meet the criteria described, will be pended for medical review

» The payment associated with the readmission claim will be held until the completion of the medical review process

» If the claim is determined to have been preventable by the hospital, the payment associated with the readmission claim will be disallowed

» Alternatively, if upon the medical review it is determined the hospital would not have been able to prevent the readmission, the claim will be paid under DRG methodology

PRICING EXAMPLES

Claim / Encounter Information Value

Submitted Charges $84,000.00Length of Stay (Admit through Discharge)

3

Medicaid Covered Days 3

Transfer No

Patient Age 55

Provider ID XXXX

DRG (knee joint replace) 3022

Final Allowed Amount ValueCovered Day Reduction Factor 1.00

Provider DRG Transition Multiplier 0.9685

Final Base DRG Payment $8,586.23

Final Outlier Add-on Payment $0.00

Final Allowed Amount $8,586.23

Base Payment Information ValueDRG Relative Weight 1.6326

DRG Base Rate $5,430.29

High Medicaid Volume Hold Harmless adjustor

1.00

Max of DRG Service Adjustor And DRG Age Adjustor

1.00

Unadjusted DRG Base Payment $8,865.49

Outlier Add-on Payment Value

Hospital Specific CCR 0.2370

Claim Cost $19,908.00

Fixed Loss Amount $65,000

Outlier Threshold $73,865.49

Marginal Cost Percentage 80%

Unadjusted Outlier Add-on Payment $0.00

Note: The Final Reimbursement Amount to providers is subject to other insurance paymentsand prompt pay adjustments

PRICING EXAMPLE – BASIC EXAMPLE


Submitted Charges $350,000Length of Stay (Admit through Discharge)

10


Transfer No

Patient Age 55

Provider ID XXXX





Final Outlier Add-on Payment $7,038.68





1.00


1.00








Unadjusted Outlier Add-on Payment $7,267.61


PRICING EXAMPLE – OUTLIER EXAMPLE



3


Transfer No

Patient Age 8

Provider ID XXXX










1.00


1.25

Unadjusted DRG Base Payment$11,081.8

6









PRICING EXAMPLE – MAXIMUM POLICY ADJUSTOR EXAMPLE


Submitted Charges $84,000.00

Length of Stay (Admit through Discharge)

1


Transfer Yes

Patient Age 55

Provider ID XXXX


Final Allowed Amount0 Value

Covered Day Reduction Factor 1.00





Base Payment Information Value

DRG Relative Weight 1.6326



1.00


1.00

DRG National Average LOS 3.30










PRICING EXAMPLE – TRANSFER EXAMPLE



5


Transfer No

Patient Age 55

Provider ID XXXX










1.00


1.00










PRICING EXAMPLE – COVERED DAY EXAMPLE

» Recipient is enrolled in the Federal Emergency Services Program (FES)

» Recipient gains Medicaid eligibility after admission into the hospital

» Recipient loses Medicaid eligibility after admission and before discharge

PRICING EXAMPLE – REASONS FOR COVERED DAYS ADJUSTMENT

» The Final Reimbursement Amount will be calculated as:

» Final Reimbursement Amount = Final Allowed Amount

- Other Insurance Payment

+ / - Prompt Pay Adjustment

Note: The current prompt pay policy (slow pay penalties and quick pay discounts) will continue to apply.

PRICING EXAMPLE – FINAL REIMBURSEMENT AMOUNT

DOCUMENTATION AND CODING IMPROVEMENT

The Need for a Documentation and Coding Adjustment:

» Documentation and Coding Improvement (DCI) is necessary, and as such are expected to be made by providers as an appropriate response to the coding requirements under the APR-DRG model

» Because the same level of coding rigor was not required for payment purposes under the legacy per diem model, AHCCCS expects that case mix will increase as a result of DCI coding once the system is implemented – beyond actual increases in acuity

» To maintain budget neutrality, it will be necessary to incorporate an adjustment to offset increases in case mix after implementation

» AHCCCS expects that actual payments, in the aggregate, will be greater than simulated amounts, and as such, resulting actual payments will remain budget neutral


Preemptive adjustment» Up-front 3 percent adjustment for expected Documentation and Coding

Improvement (DCI)› Simulate a 3% casemix increase and determine an adjustment factor

(“DCI Factor”) that would be necessary to maintain budget neutrality› Claim allowed amounts (including the base DRG payment, outlier

payment or transfer payment) will be reduced by the DCI factor› With a 3% casemix increase, the DCI factor is 0.974


DCI measurement

» Periodically (and based on the availability and completeness of data) AHCCCS will measure actual increases or decreases in case mix attributable to DCI – or “Casemix Differential”

» Based on measurement -› AHCCCS intends to set the DCI Factor for the next year based on actual

measured Casemix Differential› If measured Casemix Differential is significantly different (more than 1

percentage point higher or lower) from the initial 3% assumption, further adjust the DCI Factor for the next year to prospectively correct for the previous year(s)


DCI measurement (continued)

» Measure actual increases in acuity using Medicare’s MS-DRG grouper and Medicare relative weights – › Assumes that measuring actual changes in casemix using MS-DRGs is a

reasonable proxy for measuring actual change in acuity› Assumes that hospitals have already responded to documentation and coding

standards needed for payment under MS-DRGs

» Measure increases in acuity using APR-DRG grouper and relative weights using the same encounters

» The Casemix Differential is the difference between MS-DRG and APR-DRG casemix increases – › For example, for the same 12 month period, if MS-DRG casemix increases 1%,

and APR-DRG casemix increases 4%, the Casemix Differential – the amount attributable to DCI – is 3 percentage points


Year 1 Claims (DOS 10/1/14 – 9/30/15)

Year 2 Claims (DOS 10/1/15 – 9/30/16)

Apply DCI Factor to Reflect 3% Reduction in CMIAllowable Corridor is from 2% to 4%

Apply DCI Factor –Modify Based on Year 1 MeasurementIncrease or Decrease Factor to Correct for Year 1 Over or Underpayment

10/1/14 10/1/15 10/1/1710/1/16

Measure CMI Differential

Year 3 Claims (DOS 10/1/16 – 9/30/17)

10/1/18

Apply DCI Factor –Modify Based on Year 2 MeasurementIncrease or Decrease Factor to Correct for Year 2 Over or Underpayment


Example Scenario

Example 10/1/15 CMI differential measurement

» AHCCCS intends to measure CMI Differential using available Year 1 encounters.

» Set Year 2 DCI Factor to be equal to measured Year 1 CMI Differential

» Adjust Year 2 DCI Factor to correct for Year 1 overpayment or underpayment:› If measured Year 1 CMI Differential is within allowable corridor, make no adjustment› If measured Year 1 CMI Differential exceeds 4%, increase Year 2 DCI Factor by the

difference between actual measured and 4%› If measured Year 1 CMI Differential is less than 2%, decrease Year 2 DCI Factor by

the difference between actual measured and 2%



» AHCCCS intends to measure CMI Differential using available Year 2 encounters› Alternatively use available encounters with DOS between 10/1/14 and date of

measurement

» Set Year 3 DCI Factor to be equal to measured Year 2 CMI Differential

» Adjust Year 3 DCI Factor to correct for Year 2 overpayment or underpayment:› If measured Year 2 CMI Differential is within allowable corridor, make no

adjustment› If measured Year 2 CMI Differential exceeds Year 2 DCI factor by more than 1

percentage point, increase Year 3 DCI Factor by the difference› If measured Year 2 CMI Differential is more than 1 percentage point below the

Year 2 DCI factor, decrease Year 2 DCI Factor by the difference



» Rebase System Go Live – new rates become effective

» Begin rebasing process 9-12 months prior to go live date

» Use most current 12 months of complete encounter data

» Based on results of previous analyses, determine need for additional DCI adjustments for 10/1/17, and going forward.


ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APR-DRG Payment System Implementation February 6, 2014 -...

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Transcript of ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APR-DRG Payment System Implementation February 6, 2014 -...