PowerPoint Presentation · Comprehensive Care for Joint Replacement (CJR) k ©Pathway Health 2013...

4/6/2016

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©Pathway Health 2013

Comprehensive Care for Joint Replacement

(CJR) Model

Lisa Thomson

Chief Marketing and Strategy Officer

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Current Initiatives

C

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Hea

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Medicare Value Based Purchasing

Medicaid Reform

Performance based pay

Quality metrics

New-Performance Measures

Publically Reported Data

New Payment Model Expectations

Financial Risk Increase

Qu

alit

y In

cen

tive

–Li

nk

to p

aym

ent

Current

FFS

Episodic

Management

Shared Savings

ACO Shared Risk

Ultimate Goal

Global Payment

Quality

Incentive

Ne

w S

tan

dar

ds

and

Exp

ect

atio

ns


Medicare VBP - Payment Demonstration Model

Payment Models

– Medicare Share Savings Program

– Medicare Acute Care Episode

– Integrated Health Networks (many)

– Dual Eligible Programs

– PACE

– Bundle Payments for Care Improvement

• Defined by episodes for care

• Set target price and quality measures

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• Bundled Payment

– Single payment for an array of services that may include multiple providers and multiple settings within an episode of care

– Traditional Medicare

– Traditional state-managed FFS Medicaid

– Private payers in Commercial insurance or managed Medicare or Medicaid

– Diagnosis Related Grouping (DRG) used for hospital reimbursement. Multiple other model designs exist.

BPCI

7©Pathway Health 2013

BPCI


• Acute myocardial infarction Read MoreAmputation Read MoreAtherosclerosis Read MoreAutomatic implantable cardiac defibrillator generator or lead Read MoreBack and neck except spinal fusion Read MoreCardiac arrhythmia Read MoreCardiac defibrillator Read MoreCardiac valve Read MoreCellulitis Read MoreCervical spinal fusion Read MoreChest pain Read MoreChronic obstructive pulmonary disease, bronchitis/asthmae Read MoreCombined anterior posterior spinal fusion Read MoreComplex non-Cervical spinal fusion Read MoreCongestive heart failure Read MoreCoronary artery bypass graft surgery Read MoreDiabetes Read MoreEsophagitis, gastroenteritis and other digestive disorders Read MoreDouble joint replacement of the lower extremity Read MoreFractures femur and hip/pelvis Read MoreGastrointestinal hemorrhage Read MoreGastrointestinal obstruction Read More

Hip and femur procedures except major joint Read More

Lower extremity and humerus procedure except hip, foot, femur Read More

• Major bowel Read MoreMajor cardiovascular procedure Read MoreMajor joint replacement of the lower extremity Read MoreMajor joint replacement of upper extremity Read MoreMedical non-infectious orthopedic Read MoreMedical peripheral vascular disorders Read MoreNutritional and metabolic disorders Read MoreOther knee procedures Read MoreOther respiratory Read MoreOther vascular surgery Read MorePacemaker Read MorePacemaker Device replacement or revision Read MorePercutaneous coronary intervention Read MoreRed blood cell disorders Read MoreRemoval of orthopedic devices Read MoreRenal failure Revision of the hip or knee Read MoreSepsis Read MoreSimple pneumonia and respiratory infections Read MoreSpinal fusion (non-Cervical) Read MoreStroke Read MoreSyncope and collapse Read MoreTransient ischemia Read MoreUrinary tract infection Read More

BPCI


Mandatory Bundle


• Began April 1st - First mandatory APM!

• Five year demonstration program

• 90 day episode bundle including hospital stay

• Mandatory for approximately 800 hospitals in 67 locations (MSA)

• Acute Care bears financial risk

– 90 days post DC

– MS – DRG’s 469 and 470 (Major lower joint replacement

• Shared Savings

– Tied directly to specified quality measure performance targets

• Hospitals and Physicians have finalized data– Partnerships

– Referrals

– Network – drive referrals to lower cost settings

– Clinical systems

• $7 billion market for Medicare joint replacement cost in 2014

• Projected Savings to Medicare - $153 million

Comprehensive Care for Joint Replacement (CJR)

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“Starting April 1, 2016, 67 areas of the country will participate in a CMS-mandated bundled payment model.

• The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for Medicare Part A beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements.

• This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.” ~CMS

Description

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The most common inpatient surgery for Medicare beneficiaries

• In 2014, there were more than 400,000 procedures

Can require lengthy recovery and rehabilitation periods

• In 2014, Medicare spent $7 billion for the hospitalizations alone

Quality and costs of care still vary greatly among providers

• Infections, implant failures can be 3 X’s higher at some hospitals

• $16,500 to $33,000 for surgery, hospital, & recovery across geographic areas

Hip and Knee Replacements (CMS Data)


7%4%

56%

3%1%

29%

Total Joint Replacement Spend Breakdown

Surgeon 7%

Readmission 4%

Hospital 56%

Pre-operative 3%

Other Consults 1%

Post Hospital (PAC, DME, Medication) 29%


http://federalregister.gov/a/2015-29438

The Centers for Medicare & Medicaid Services have implemented a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model (formerly using the acronym CCJR), in which acute care hospitals in

certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement or

reattachment of a lower extremity (LEJR).

CJR Model: Final Rule


July 9, 2015

• Proposed CJR rule published

September 8, 2015

• Comment period for CJR rule ended

November 16, 2015

• CMS finalized CJR regulations

April 1, 2016

• First performance period will begin

Timeline

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Hospitals

Physicians, HHA, SNF, & Others

Coordinated Care for

Beneficiaries

CJR Goal


21st

Century

BetterCare

Better Health

Lower Cost

Affordable Care Act Goals

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Medicare fee-for-service payments made via alternative payment

models:

30% by 2016

50% by 2018

Medicare Goals

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2016 2018


1• Hospital held financially accountable for the quality and cost of the CJR

episode of care

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• MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complications or comorbidities

• MS-DRG 470: Major joint replacement or r4eattachment of lower extremity without major complications or comorbidities

3• Episode of care continues for 90 days following discharge

Reach the Goal Through Hospitals

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• Admission to a participating hospital and ultimately discharged under MS-DRG 469 or 470

Beginning

• 90 days post discharge

End

Episode Definition


Episode of Care Partners

Others

Physicians

Post Acute Care

• Bundled Items & Services

– Physicians

– Inpatient hospital admissions & re-admissions

– Inpatient psychiatric facilities

– PAC: LTCH, IRF, SNF, HHA

– Outpatient therapy

– Clinical labs

– DME

– Part B drugs

– Hospice

– Some care management payments

Hospital Partners

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• 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

• Excluded MS-DRGs and ICD-10-CM diagnosis codes

Exclusions


https://innovation.cms.gov/initiatives/cjr

Model: 67 MSAs, ~ 800 Hospitals

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Madison

The Monroe Clinic

Divine Savior Healthcare

St. Mary’s Hospital

University of Wisconsin Hospitals and Clinics Authority

Milwaukee

Waukesha Memorial Hospital

Columbia Center, St. Mary’s Hospital Milwaukee, St. Mary’s Hospital Ozaukee

Aurora Medical Centers, Washington County, St. Luke’s, West Allis

Oconomowoc Memorial Hospital

St. Joseph’s Community Hospital of West Bend

Wheaton Franciscan Healthcare-St. Francis, St. Joseph, Franklin

Community Memorial Hospital

Froedtert Memorial Lutheran Hospital

Orthopaedic Hospital of Wisconsin

Midwest Orthopedic Specialty Hospital

Actual Wisconsin Hospitals

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CMS Regions for Target Pricing


Data.Medicare.gov


• MS-DRG 469 and MDS-DRG 470

• With Hip Fx vs. Without Hip Fx

• Blend

– Hospital-specific historical spending

– Regional spending for LEJR episodes

• Regional component increases over time

• All providers will be paid throughout the year under existing Medicare payment systems

Target Prices

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MS-DRG Reimbursement to

Hospital

Actual Spending Analyzed by CMS at End

of Each Program Year

Additional Payment to Hospital or Repayment

to CMS

Retrospective Bundled Payments


• Actual Spending Below Target Price + Quality = Up to 5% of target price

Years 1 & 2

• Actual Spending Below Target Price + Quality = Up to 10% of target price

Year 3• Actual Spending

Below Target Price + Quality = Up to 20% of target price

Years 4 & 5

Hospital Incentives

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• No responsibility to repay Medicare

Year 1

• Capped at 5% of target price

Year 2• Capped at 10%

of target price

Year 3

• Capped at 20% of target price

Years 4 & 5

Hospital Disincentives


Warning Letter

Plan of Correction

Reduce or Remove

Incentives

Increase Repayment

Amount

Expulsion

Non-Compliance Measures

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Quality First

• Minimal level of episode quality before receiving reconciliation payments when spending is below target

Performance and Improvement

• Hospital-Level Risk-Standardized Complication Rate for THA &/or TKA (NQF#1550)

• Hospital Consumer Survey (NQF#0166)

Avoidance of Expensive and Harmful Events

• Goals for all hospitals

Tools

• Relevant spending & utilization data

• Waiving some Medicare requirements

• Sharing best practices

Quality and Pay-for-Performance


BPCI and CJR

Source: American Hospital Association http://www.aha.org/content/16/issbrief-bundledpmt.pdf


Retain freedom of choice

Existing safeguards remain in

place

Additional monitoring of claims

data

Beneficiary Benefits & Protections


WaiversTelehealth

Visits

Home Visits for Non-

HomeboundCollaborations

Additional “Flexibilities”

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3 Day Rule Waived

• Following anchor hospitalization

• Begins in Year 2

3 Star or Higher SNF

• 7 of the previous 12 months

Discharges

• No premature discharges to SNF

• Beneficiaries must be able to exercise freedom of choice

SNF Waiver

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Implications for Stakeholders

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• Hospitals – accountability and risk

• Physicians – coordination of outcomes with acute, decrease variation, evidenced based care and best practice

• IRF – shift to lower cost settings, care complexity

• PAC – networks, care paths, delivery patterns

• SNF – ALOS, efficient, high quality, less costly care

• HHA –benefit from being lower cost provider, essential to bundle savings

• Payer – keeping close eye on success of CJR

Stakeholders

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Impact to Post Acute Care (PAC) Providers

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But before we discuss focus points …

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• Beneficiary Notifications

• This CMS-issued notification form is not modifiable by any entity or individual unless otherwise indicated in the form.

• Please see § 510.405 of the Comprehensive Care for Joint Replacement Final Rule for all requirements surrounding beneficiary notification.

– The final rule can be accessed here: https://www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals.

• In order to aid monitoring and compliance efforts, CMS recommends all CJR hospitals and their collaborators maintain a list of beneficiaries that receive these notification documents.

Beneficiary Notifications

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Centers for Medicare & Medicaid Services

Comprehensive Care for Joint Replacement Model

Post-acute care provider/supplier Notification Letter

[Post-acute care provider name] has entered into a financial arrangement with [Hospital name] for participation in the Comprehensive Care for Joint Replacement (CJR) model. Through this arrangement, [Hospital name] may share payments received from Medicare as a result of reduced

episode of care spending and hospital internal cost savings with [Post-acute care provider]. [Hospital name] may also share financial accountability for increased episode of care

spending with [Post-acute care provider].

Beneficiary Notifications


1 Most spending variations are in the PAC setting

2 IRFs are the most expensive PAC setting

3 Readmissions are the most significant cost driver

4 SNF length of stay is a significant cost driver

5 Measures for recovery or outcomes don’t exist or are unclear

6 Bundled payments provide opportunities for non-conventional strategies

7 Know your value

PAC Focus Points

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DataGen Healthcare Analytics 2015

Spending Variations


This is about Medicare spending, not internal costs; therefore, the acute inpatient payment component of the bundle is always the same.

Hospitals must evaluate the efficacy of physicians’ post-acute care plans and work to

reduce Medicare spending in PAC settings.

The most successful CJR hospitals will reduce the incidence and magnitude of institutional

PAC.

PAC Spending Variations

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DataGen Healthcare Analytics 2015

IRFs Are Expensive


Average Episode Spending by First PAC Setting

IRF

~$36,000

SNF

~$32,000 HHA

~$28,000

Self-Care

~$16,500

IRFs Are Expensive

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• Hospitals understand

– Most significant opportunity to increase gain or decrease loss occurs in PAC setting

– Average of 45% of all episode payments occur after the anchor DC

• Biggest variable –

– READMISSIONS

– ALOS PAC

– Intensity of rehabilitation

• Alignment with providers who demonstrate ability to efficiently provide high quality care

Data and Outcomes


Readmission rate for joint replacements is generally low; however, Medicare payments for the episode

are doubled when a patient is readmitted.

Why?

Major joint readmissions tend to be for revisions or surgical complications, after which the PAC work

generally starts all over.

Readmissions Are Expensive

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SNFs are the only PAC setting paid on a per diem basis by Medicare Part A.

There are 2 expense drivers for SNF care:

Length of Stay and Case Mix.

Even small LOS reductions can help reduce Medicare spending (and SNF revenue).

SNF Lengths of Stay (LOS)


No rigorous, comparative standards for benchmarking; only anecdotal evidence.

CJR data will provide data.

New SNF QMs will provide data as well!

Recovery and Outcome Measures

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New SNF QMs


Care Coordination

Telehealth

Home Delivered Meals

Transportation for Shopping, Outpatient Therapy

Potential episode savings generated by providing the services may cover the costs!

Opportunities

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Knowing your value is the key to success!

How do you compare to your competition and to best practices?

Without this information, PAC providers are at risk!

“Low Spend” Providers have an advantage.

“High Spend” Providers will have to justify the higher cost or rectify it.

Your Value


For the CMS bundled payment system to work, hospitals will need to recruit high-

quality post-acute care partners.

Know Your Value

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Know Your Value


• Decrease SNF LOS

• Skip a SNF

• Build a SNF

• Partner with a SNF

– Increase MD Continuity

– Demand Value SNF Competencies from selected SNFs

– Scalability

• Increase HHA integration

• Narrow networks

Hospital Response to CJR

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Leadership Strategies

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• Not in my marketplace?

• Think again!

• CJR is the beginning

• Change operations and approach to care now

Whew…

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5 Star RatingQuality

MeasuresCustomer

Satisfaction

Costs of CareHospitalization

Rate

Other Data?

Other Care Models

What Do You Need To Know?

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Strategies for Success

So

urc

e –

Path

way

Hea

lth

Assess Readiness

Data and Technology

Capabilities and

Competencies

Partner and Collaboration


• Document your delivery of care and services:

– Quality services

• Satisfaction survey (LTSS and PAC – separate)

• Overall ranking – 5 star and SNF performance measure

• Readmission

• ALOS per disease state

• TCOC

• HCC

• Clinical practices – evidenced based

• Care transition/care coordination

Becoming a valued partner

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• “ a business or marketing statement that summarizes why a consumer should buy a product or use a service. This statement should convince a potential consumer that one particular product or service will add more value or better solve a problem than other similar offerings.”

• Create a Business Case –tell your story

• Service Delivery

• Staffing Model

• Specialties

• QAPI

• Key metrics

• Cost containment

• Communication

• Partnerships

Val Prop - Create

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Leadership• Change agent – drive change through

“collective” creativity

• Refine and shape the culture

– (listen, appreciation and optimism)

• Embrace the challenge

– Lead creativity and innovation

• Acknowledge the essentials that should not change

• Think BIG! Look to the “road” ahead

• Energetic and Passionate – the fuel for change


Thank You

Lisa ThomsonChief Marketing and Strategy Officer

Pathway Healthwww.pathwayhealth.com

(651) 407-869968

http://www.pathwayhealth.com/

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