4/26/2016. The future is not what it used to be. Driving Transformation for Comprehensive Care for Joint Replacement (CJR) Understand Redesign Align

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1 Driving Transformation for Comprehensive Care for Joint Replacement (CJR) Redesign Align 22 ND A N N U A L M ID W E S T C A R E C O O R D IN AT IO N C O N F E R E N C E The future is not what it used to be. YO G I B E R R A TODAY S SPEAKER Jennifer Johnson, BSN Director, Alignment Strategy and Reform Focus: Partners with clients to identify and implement operational and organizational opportunities for advancement within today's valuebased payment models. Clients include providers engaged in BPCI and CJR. Experience: 20 years in healthcare bridging the gap between clinical and business priorities to improve patient care 10 years managing teams in program development, program management program implementation 1

2 VOLUNTARY MANDATORY 4/26/2016 DISCLAIMER: Stryker Performance Solutions does not practice medicine and assumes no responsibility for the administration of patient care. This material and/or presentation is provided for guidance and/or illustrative purposes only and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from a healthcare provider. AGENDA The transition to Value-Based Care CJR Education: Overview of Program Components Critical Success Factors in CJR Key Strategies of Care Redesign Questions THE RAPID TRANSITION TO VALUE-BASED CARE October 2013 to October 2015 Bundled Payment for Care Improvement cohorts went live January 28, 2015 Health Care Transformation Taskforce (group of nation s largest health systems and insurers) announces 2020 goal of shifting 75% revenue tied to alternative payment models March % OF MEDICARE PAYMENTS ARE TIED TO ALTERNATIVE PAYMENT MODELS (ACOS/BP) 2020 Health Care Transformation Taskforce (75% adherence): CMS setting a trend and entire market is shifting November 16, 2015 CJR Announced: 2009 Final rule posted Acute Care Episode (ACE) demonstration to test the use January 26, 2015 of a bundled payment for both hospital and physician U.S. Department of Health July 9, 2015 services for a select set of and Human Services (HHS) inpatient episodes of sets goals and timeline for CJR Announced: Mandatory care for orthopedic and Medicare reimbursement shift Total Joint episode-based cardiovascular procedures from volume to value bundled payment model for DRGs 469 & % OF MEDICARE PAYMENTS TIED TO ALTERNATIVE PAYMENT MODELS (ACOS/BP) 2

3 CJR OVERVIEW The Comprehensive Care for Joint Replacement Model Mandatory bundled payment model for Total Joint Replacement and reattachment of the lower extremities (DRGs 469 & 470) Separate Target Pricing for elective and Hip Fracture patient population 67 metropolitan statistical areas (MSA) / 800+ hospitals Launched on April 1, 2016 (5-year duration) CMS-defined, required quality metrics Target price based on blended hospital and regional spending Retrospective annual reconciliation Excludes episodes covered under an existing Bundled Payments for Care Improvement contract Acute Care Hospital Stay and Post-Acute Care 90 Days Post-Discharge FINAL CJR PARTIC IPATING MSAS OPTIMIZ ING THE ORTHOPED IC VALUE CHAIN The Total Joint episode of care represents a significant opportunity to improve quality through reduced variation, resulting in decreased cost. S N F I P P A C Average DRG Day Episode Cost HHA R E A D MISSI ON TOTAL COST* P H YS I CI AN O U T P ATI ENT QUALITY I N P A TIENT PA S T F O C U S Addressing this segment of the episode is going to be a new focus under CJR and potentially a challenge for Hospitals to manage C J R F O C U S * Cost to Medicare 3

4 DRG 470 EPISODE COST BY FIRST SITE OF SERVICE $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $- Average Episode Cost by FFS $38,608 $32,136 $20,375 $18,420 HOME HHA SNF IPPAC Index Admit Professional OP_DME Readmits HHA SNF Other IP PAC Patients discharged home or with home health have far lower episode costs than SNF and IP PAC discharges. Note: Index Admission cost is set is equal to the National Average Index Admission cost to normalize for wage index differences. includes national average episode costs for DRG 470. The costs are not trimmed and are based on episodes initiated during the first 3 quarters of Costs reflect actual wage index and other payment adjustments that vary by facility Source: SPS analysis using 2014 CMS data. THE RISING BAR OF CJR I N C R E A S I N G R E L I A N C E O N R E G I O N A L P E R F O R M A N C E Y E A R 1 Y E A R 2 Y E A R 3 Y E A R 4 Y E A R 5 Risk Model Limited upside potential only Limited upside and downside More upside and downside risk Maximum allowable Maximum allowable upside and upside and downside risk downside risk Historical HOSPITAL Performance Weighting 66.6% 66.6% 33.3% 0% 0% Historical REGIONAL Performance Weighting 33.3% 33.3% 66.6% 100% 100% Range for Discount used for Reconciliation Amount; Determined by Composite Quality Score 1.5%-3% 1.5% 3%* 1.5% 3%* 1.5% 3% 1.5% 3% Loss/Gain Cap No loss 5% gain cap 5% loss cap 5% gain cap 10% loss cap 10% gain cap 20% loss cap 20% gain cap 20% loss cap 20% gain cap * The discount for repayment amount purposes is 1% lower in years 2 and 3, effectively 0.5% - 2%. THE RISING BAR OF CJR Hospitals will be pressured to improve their baseline episode performance to outpace the rest of their region H I S T O R I C A L YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 H O S P I T A L P E R F O R M A N C E H I S T O R I C A L R E G I O N A L P E R F O R M A N C E Regional markets will become increasingly competitive as bundled payment programs, including BPCI, continue to evolve and drive target prices down Those who can t compete we expect to see: Joint programs marginalized Consolidation Unprofitability 4

5 CJR COMPLIANC E REQUIREMEN TS CMS may add 25% to a repayment amount on a participant hospital's reconciliation report if the participant hospital fails to timely comply with a corrective action plan or is noncompliant with the model's requirements. General Program Compliance Hospital compliance plan that includes CJR Board level oversight of CJR Written policies for selection of collaborators with established quality criteria Hospital oversight of compliance with collaborators Hospital Beneficiary Notification Compliance Patient CJR education upon admission Patient notification of PAC provider options CJR COMPLIANC E REQUIREMEN TS, CONT D. Collaborator Beneficiary Notification Requirements 1) CJR Physician: Required to provide written notice of the structure of the CJR model and the existence of the sharing arrangement with the hospital at the time the decision for surgery is made 2) CJR PAC Provider/Supplier: Required to provide written notice of the existence of the CJR sharing arrangement with the hospital at the time the beneficiary first receives services during the episode Collaborator Compliance Plan Collaborators must have their own compliance plan in place related to CJR CJR CRITIC AL SUCCESS FACTORS Episode Collection and Analytics where you are, where you need to focus and how your results are emerging Provider Alignment Creating the right formal/informal agreements to drive provider alignment through impactful engagements that help improve care and reduce cost under the bundle Align Providers Redesign Care Care Redesign Implementation Episode-focused care redesign that helps improves quality care, reduces variation and decreases cost across the continuum 5

6 UNDERSTAND YOUR DATA Use your internal hospital data to measure historical, current and ongoing performance within your facility Process your external CMS claims data to understand CJR program, opportunities, risks and impact Capture patient reported outcomes (clinical and functional) and satisfaction to help improve quality composite score Validate your CMS data for accuracy and discrepancies Analyze reconciliation data to inform gainsharing models ing your data is more than data collection, it is the action plan for care transformation and provider alignment. UNDERSTAND YOUR DATA Internal Collection and Analytics Hospital Reported Outcomes Dashboards that track and benchmark hospital performance Patient clinical, functional and satisfaction outcomes Maximize key opportunities for CMS payments Gainsharing metric reviews Especially useful when gainsharing on internal cost savings, normally complicated and contentious calculations CJR requires achievement of certain levels of performance in a composite quality score in order to receive any annual cost savings UNDERSTAND YOUR DATA External Claims Bundled Payment Analytics Detailed financial and actuarial analysis on CMS claims data Manipulate, review and interpret your data for variation and opportunity assessment Reconcile your CMS claims data to help ensure you re maximizing payment Review of CMS provided target price for reasonableness Benchmark your performance vs. your history, your region and best practice CJR dashboard and reporting Volume and episode cost analysis Post-acute analysis Readmissions Preliminary estimated NPRA Gainsharing structuring and calculations Use CMS claims and quality data to help you structure and drive your program CJR requires achievement of certain levels of performance in a composite quality score in order to receive any annual cost savings 6

7 UNDERSTAND YOUR DATA Composite Quality Scoring Your financial outcomes will be directly impacted by your quality performance Each quality measure is weighted to impact the overall composite score Total composite score determines: 1. Eligibility to receive positive Net Payment Reconciliation Amounts (NPRA) 2. Target price discount rate for reconciliation payment and repayment Quality Measure Weight Contributed to Composite Score THA/TKA Complications 50% HCAHPS 40% PRO 10% UNDERSTAND YOUR DATA Composite Quality Score: Payment and Repayment Performance Year Composite Quality Score Quality Category Eligible for Reconciliation Payment Eligible for Discount for Quality Incentive Reconciliation Payment Payment Discount for Repayment Amount 1 <4.0 Below Acceptable No No 3.00% Not applicable 4.0 and <6.0 Acceptable Yes No 3.00% Not applicable 6.0 and 13.2 Good Yes Yes 2.00% Not applicable >13.2 Excellent Yes Yes 1.50% Not applicable 2-3 <4.0 Below Acceptable No No 3.00% 2.00% 4.0 and <6.0 Acceptable Yes No 3.00% 2.00% 6.0 and 13.2 Good Yes Yes 2.00% 1.00% >13.2 Excellent Yes Yes 1.50% 0.50% 4-5 <4.0 Below Acceptable No No 3.00% 3.00% 4.0 and <6.0 Acceptable Yes No 3.00% 3.00% 6.0 and 13.2 Good Yes Yes 2.00% 2.00% >13.2 Excellent Yes Yes 1.50% 1.50% Quality hurdle for reconciliation eligibility: participant must have a hospital composite score of 4 or greater to qualify and receive positive NPRA UNDERSTAND YOUR DATA VOLUNTARY PATIEN T REPORTED OUTCOMES The percent of eligible procedures to be reported ramps up by performance year from 50% in year 1 to 80% in year 5 Reporting of PRO adds to the overall composite score which reduces the discount on target prices Timing of collection for post-op data elements is between days Final PRO Elements Date of birth Race Ethnicity Date of admission Date of procedure HIC# Body mass index Total painful joint count Chronic narcotic use Quantified spinal pain SILS2 questionnaire VR-12 OR PROMIS-Global KOOS HOOS 7

8 REDESIGN YOUR CARE Redesign Care Prioritize Care Redesign Efforts Leveraging your episode data to redesign care to help drive success under CJR. Building alignment between the hospital, providers and staff. Standardizing clinical protocols and care pathways. Reducing variation to help improve quality and patient satisfaction. Care coordination across the entire continuum. Streamlining post-acute utilization and optimization. ALIGN YOUR PROVIDER S Align Providers Considerations for Alignment with Providers to Optimize Provider Engagement Compliance with CJR compliance regulations Foster collaboration with select, proven-value providers (surgeons and post-acute providers) Incentivize providers to change practice patterns Utilize data and targets to help drive fair and compliant gainsharing Care Coordination is critical, but designing an Alignment Strategy that incentivizes provider engagement will help drive success under CJR. NOTE: All gainsharing structures must be independently evaluated by the client and their legal counsel for compliance with legal and regulatory gainsharing requirements. Stryker Performance Solutions does not provide legal advice. ALIGN YOUR PROVIDER S Align Providers Collaborator Agreements The content of the collaborator agreement outlined in the final rule resembles items that are required by CMS for BPCI in the form of an implementation protocol. Likely elements include: Information about planned care redesign and care coordination A description of how success will be measured Management and staffing information Required to ensure that the collaborator is in good standing with Medicare and has a valid TIN or NPI Collaborator must have a CJR compliance program Methodology for accruing and calculating internal cost savings Describe quality criteria for the collaborator Note: Collaborator must meet hospital defined quality criteria in order to receive a gainsharing payment. 8

9 Care Redesign Strategies PREOP CARE 30 Days 1-3 Days 90 Days BEST Practice Expectation Setting LOS, appropriate discharge disposition, patient responsibility, family involvement Preop Education Mobility, functional goals, plan of care for safety, pain management, key to achieving goals Achieve maximum attendance rate Phone call Preop Optimization 30 Day preop process, effective preop screening, medical clearance Essential diagnostics and imaging Preop Discharge Planning Critical time for messaging for Home is best Prepare dual d/c plans as needed New: High-risk Patient Screening Preop: Identify high-risk patients during preop RAPT tool ASA,others New focus on patient selection Include education in preop class HOSPITAL CARE 30 Days 1-3 Days 90 Days BEST Practice Clinical Protocols Anesthesisa, pain, mobility, respiratory, blood and infection prevention Medical Management Consistent learn the TJR population, program protocols, mange costs and LOS Members of the team Reinforce Education Patient, family confidence and ability to d/c home Daily Multidisciplinary Rounds Discharge readiness; clinical functional, social Adjust d/c plan as necessary Manage the LOS Must Do Better: Discharge to Home Discharge to most appropriate level of care at the right time biggest opportunity 80/20 Rule & Home is best! Safety Ability Comfort Is there value to an extra day? SNF, IRF and HH ; use these plans for exceptions only Consider Beneficiary Incentive Waiver New: Discharge Planning Measures Integrated Case Management Verbal handoffs to SNF/HH staff Drives accountability Best for patient Safety, Readmission, Satisfaction 9

10 POST-ACU TE CARE 30 Days 1-3 Days 90 Days BEST Practice 30 Days after Discharge Patient Call Backs Within a few days of discharge Focus to ensure patients doing well at home HCAHPS Reunion Luncheon New: 1. Manage the Patient for 90 Days Ensure patient is successful following discharge in any setting: Achieve quality outcomes Improve patient experience Deliver cost effective care Who is involved? SNF, HH our new partners We need each other Select your partners Star Rating by Nursing Home Compare + Collaboration Agreements How do we do it? Find out what s working & opportunities Define common goals Define success metrics PAC improvement team meetings to assess performance POST-ACU TE CARE New: 2. Manage the LOS of SNF / Inpatient Rehab Stays Introducing. The Extended Care Pathway Description: Using a set of defined functional criteria, evaluate your patients at regular intervals to determine readiness to transition to :the next level of care Key Steps: Define functional criteria Set minimum expected LOS timeframes Allow some individualization (80/20) for poor health status/prior level of function Establish review process/frequency Educate physicians and office staff Track your compliance with the process Evaluate process for effectiveness POST-ACU TE CARE New: 3. Readmission Tracking Purpose: to reduce and prevent postop readmissions Key Steps: Identify your population: All TJR All screened high risk TJR patients All SNF/IRF discharge Do you include Fx. Hips? $1205 L L l Identify the process for tracking readmissions Phone calls to patients, to SNF / IRF? How often? Develop a tracking tool Identify action plan for patient concerns Notification from ED physician to Ortho surgeon for any TJR that presents to ED Decision to admit or place in observation Screen for Hi-risk Track Outcomes 10

11 POST ACUTE CARE New: 4. Managing the Entire Continuum of Care: Staffing Staffing: Preop/Hospital Current activities usually well managed by Program Coordinator Staffing: Post-Acute Staffing needs are related to the scope of new activities built into your plan of care You must do the math Volume of selected patient population Volume of SNF/IRF discharges Volume of High-risk patients (CC/MCC) Frequency and number of phone call follow-ups or other planned activities Example: Plan of Care Follow up Phone Calls Discharge Call x1 (Home / HH and Highrisk to Home) High-risk / SNF Follow-up call at 7 days High-risk / SNF Follow-up call at 14 days High-risk / SNF Follow up call at 30 days High-risk / SNF Follow-up call at 60 days High-risk / SNF Follow up call at 90 days D/C Days B R E A K IN G D O W N S IL O S: COORDINATING CARE PERFORMANCE IMPROVEMENT TEAM Pre-Admission Anesthesia Surgeons OR Nurses Care Coordinator Nurses Case Management Physical Therapy Housekeeping Dietary Strategy Public Relations Finance Administration Post-Acute Providers CREATE CULTURAL TRANSFORMATION Previous Thinking The patient is my responsibility when they are in the hospital SNF is the typical and desirable discharge plan Insurance will cover SNF, therefore it is my right SNF is better for me (patients) than Home Home Health and Outpatient PT is inferior care It is too difficult for patients to get to Outpatient PT Current Thinking I am part of the team that manages the entire episode of care Outpatient PT is MORE, not less: in/out of car, different equipment/treatment modalities Home is better and safer for patients less risk of infection Setting expectations and education make Home a possible discharge plan Improved pain and mobility protocols make Home a safe discharge plan 5-15% of the time, SNFs and Home Health are necessary opportunity now is to reduce the number of days at SNF or Home Health DISCLAIMER: Stryker Performance Solutions does not practice medicine. The information contained in this document and/or presentation is intended to serve as an example or method of guidance only, and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from healthcare providers. Stryker Performance Solutions assumes no responsibility for the administration of patient care. 11

12 REDESIGN YOUR CARE Redesign Care What is CJR rule asking us to do? Reduce complications Reduce readmissions Improve patient satisfaction Manage care coordination across the entire continuum Work as a team to own and improve the Total Joint episode of care Be cost effective Can we accomplish this? With the hospital? With SNFs and Home Health? With patient and family willingness and participation? PHYSIC IANS DRIVE DISCHARGE DISPOSITIO N DECISION S Redesign Care Set patient expectations Recommend the level of post acute care Inform patients of high quality providers Help develop a preferred post acute pathway Physicians can influence patients post acute care decisions by recommending a clinically appropriate level of post acute care and high quality, cost effective providers. DISCLAIMER: Stryker Performance Solutions does not practice medicine. The information contained in this document and/or presentation is intended to serve as an example or method of guidance only, and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from healthcare providers. Stryker Performance Solutions assumes no responsibility for the administration of patient care. PROMOTE TOP POST ACUTE PROVIDERS W HILE MAINTAIN ING PATIENT CHOICE Redesign Care Distribute list of preferred SNF and HH providers to all patients Clearly state that the patient has freedom of choice over where they are discharged Emphasize preferred providers high quality, superior care and outcomes Physicians can have significant influence over their patients discharge disposition and post acute providers while still respecting a patient s right to choose. DISCLAIMER: Stryker Performance Solutions does not practice medicine. The information contained in this document and/or presentation is intended to serve as an example or method of guidance only, and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from healthcare providers. Stryker Performance Solutions assumes no responsibility for the administration of patient care. 12

13 SUMMARY You can t afford to wait to implement these new activities These changes are good for patients and for your service line Take control and manage the entire TJR episode of care Be confident and make improvements in the PAC episode just like you ve done in the hospital Be the leader develop new partnerships and have the new conversations Ensure your success for the future Quality Outcomes Patient Satisfaction Profitability Questions? 13