Maximizing Success in a Bundled Payment Environment Melinda S. Hancock, FHFMA,CPA Partner, DHG Healthcare 2015-16 Chair, HFMA Wisconsin January 2016
Go Beyond Current Experiences 2
Go Beyond the Status Quo It isn t the mountains ahead to climb that wear you out; it s the pebble in your shoe. Muhammad Ali 3
CMS Accelerates the Tipping Point for Everyone HHS goal of 30 percent traditional FFS Medicare payment through alternative payment models by the end of 2016 50 percent by the end of 2018 HHS Press Office 1-26-15 85% of payment tied to quality and value metrics (ex. HVBB, HRR) 100 90 80 70 60 50 40 30 20 10 0 2011 2015 2016 2018 Traditional, Fee for Service Alternative Payment Models 4
How Are We Doing? 5
Summary of Innovation Models Accountable Care Episode Based Payment Initiatives Primary Care Transformation Medicaid & CHIP Population To Accelerate Testing of New Models Speed Adoption of Best Practices ACOs BPCI Models 1-4 Advanced Primary Care Initiatives Reduce Avoidable Hospitalizations for NF residents State Innovation Models :Round 1 & 2 Beneficiary Engagement Model Advanced Payment ACO ACE Demonstration Comprehensive Primary Care Initiative Financial Alignment Incentive for Medicare & Medicaid Frontier Community Health Integration Community Based Care Transitions Comprehensive ESRD Care Initiative Oncology Care Model FQHC Advanced Primary Care Practice Strong Start for Mothers & Newborns Maryland All Payer Health Care Action and Learning Network ACO Investment Model Specialty Practitioner Payment Model Graduate Nurse Education Medicaid Innovation Accelerator Program Health Care Innovation Round 1&2 Innovation Advisors Program Next Generation ACO Model Comprehensive Care for Joint Replacement (CJR) Independence at Home Medicaid Prevention of Chronic Diseases Health Plan Innovation Initiatives Million Hearts Pioneer ACO Multi Payer Advanced Primary Care Practice Medicaid Emergency Psychiatric Demonstration Medicare Care Choices Award Partnership for Patients Rural Community Hospital Demonstration Transforming Clinical Practice Medicare IVIG Demonstration Cardiovascular Disease Risk Reduction PACE Home Health Value Based Purchasing Medicare Adv Value Based Ins Design Enhanced Medication Therapy Management Updated 11.24.15 http://innovation.cms.gov/initiatives/
Shaping the Curve Where are we heading?
X BPCI and CCJR 8
Bundled Payments for Care Improvement MODEL 1 MODEL 2 MODEL 3 MODEL 4 MODEL NAME Retrospective Acute Care Hospital Stay Only Retrospective Acute Care Hospital Stay plus Post-Acute Care Retrospective Post- Acute Care Only Acute Care Hospital Stay Only SCOPE OF EPISODES Entire Hospital Up to 48 Episodes Up to 48 Episodes Up to 48 Episodes SERVICES INCLUDED IN EPISODES All Part A services paid as part of the MSDRG Payment All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions All non-hospice Part A and B services during the post-acute period and readmissions All non-hospice Part A and B services (including the hospital and physician) during initial inpatient stay and readmissions PAYMENT Retrospective Retrospective Retrospective Prospective BPCI DISCOUNT 0.5%, and increasing over time 2-3% 3% 3-3.25% Note: Model 1 is on a different implementation timeline than Models 2, 3 and 4.
The Episodes: BPCI CMS created 48 Episodes, each with up to 15 individual MS-DRG codes DHG categorized Episodes into 9 Service Lines; illustrative purposes only Model 2, 3, or 4 applicants may select 1-48 Episodes for testing Spine (5) Cardiac Services (12) Vascular Services (3) Example DHG Category: Vascular Services Episode: Major cardiovascular procedure MS-DRGs 237 & 238 Orthopedics (10) Neurology (2) Oncology / Hematology (1) Episode: Medical peripheral vascular disorders MS-DRGs 299, 300, & 301 Pulmonology (3) General Surgery (2) General Medicine / Internal Medicine (10) Episode: Other vascular surgery MS-DRGs 252, 253, & 254 http://innovation.cms.gov/initiatives/ bundled-payments/ 10 10
How do you WIN in BPCI? 11
Optimizing Bundles Requires New Areas of Understanding DRG 470, Spending by Setting Ex. Target Price = $24k Hospital Physician HHA SNF IRF Readmit. $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30 60% of spending is outside of hospital PAC Setting vitally important to manage - Discharge status - Picking PAC partners Readmission often is over 2x the spend of non-readmitted patient
Distribution of Medicare Spend Initial focus may be in two areas of spending that make the greatest difference: readmissions and post acute care settings. PAC Setting Costs Readmission Opportunity Data provided by Dobson DaVanzo Average Episode $ All data from this slide on is based on 90-Day Episodes - Trimmed Spending (Risk Track B) in 2012 Dollars, Episodes with less than 250 count are not included, but are available. 13
Two Types of Gain Sharing Net Payment Reconciliation Amount Medicare Spend Reduction Internal Cost Savings Hospital Expense Reduction 14
BPCI Participants by Geography
1,200 1,000 800 600 400 200 0 Changes From Previous Analytic File Phase II Episodes July Analytic File Dropped Added Total Change STAC PGP SNF LTAC IRF HHA October Analytic File Type STAC 1,925 (134) 791 657 2,582 PGP 1,995 (459) 646 187 2,182 SNF 5,874 (1,011) 3,975 2,964 8,838 LTAC 1 0 6 6 7 IRF 17 0 0 0 17 HHA 373 0 144 144 517 TOTAL 10,185 (1,604) 5,562 3,958 14,143 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 STAC PGP SNF LTAC IRF HHA July Analytic File October Analytic File Phase II Unique BPCI Participants (BPCI IDs) July Analytic File Dropped Added Total Change October Analytic File Type STAC 413 (13) 0 (13) 400 PGP 440 (150) 1 (149) 291 SNF 1,065 (365) 9 (356) 709 LTAC 1 0 0 0 1 IRF 9 0 0 0 9 HHA 102 (1) 0 (1) 101 TOTAL 2,030 (529) 10 (519) 1,511 July Analytic File October Analytic File Note: Some PGPs and SNFs originally applied under separate BPCI IDs with different conveners. May be reason for decrease in IDs in some instances. Also, there should not be any added participants from July to October due to the fact that October was only for current phase II participants to add or drop episodes. The 10 added IDs could be omissions/errors from the July file that were corrected in October.
BPCI Initiative Statistics (As of October) MODEL 2 MODEL 3 MODEL 4 TOTAL Unique Unique Unique Unique Type IDs Episodes IDs Episodes IDs Episodes IDs Episodes STAC 391 2,542 9 40 400 2,582 SNF 709 8,838 709 8,838 PGP 240 2,046 51 136 291 2,182 LTAC 1 7 1 7 IRF 9 17 9 17 HHA 101 517 101 517 Total 631 4,588 871 9,515 9 40 1,511 14,143 800 Participants 10,000 Episodes 700 600 500 9,000 8,000 7,000 6,000 400 5,000 300 200 100 4,000 3,000 2,000 1,000 0 STAC SNF PGP LTAC IRF HHA 0 STAC SNF PGP LTAC IRF HHA Model 2 Model 3 Model 4 Model 2 Model 3 Model 4
Phase II Episodes by Geography * Some PGPs have applied via their corporate address
Phase II Episodes by Group Episode Frequency Major joint replacement of the lower extremity Simple pneumonia and respiratory infections Congestive heart failure Chronic obstructive pulmonary disease, bronchitis, asthma Hip & femur procedures except major joint Sepsis Urinary tract infection Acute myocardial infarction Medical non-infectious orthopedic Other respiratory Cellulitis Stroke Fractures of the femur and hip or pelvis Renal failure Esophagitis, gastroenteritis and other digestive disorders Cardiac arrhythmia Gastrointestinal hemorrhage Nutritional and metabolic disorders Lower extremity and humerus procedure except hip, foot, femur Gastrointestinal obstruction Diabetes Revision of the hip or knee Syncope & collapse Major bowel procedure Transient ischemia Medical peripheral vascular disorders 0 100 200 300 400 500 600 700 800 900 1000 Model 2 Model 3 Model 4
Phase II Episodes & Participants by Convener Conveners with > 50 Phase II Episodes MODEL 2 MODEL 3 MODEL 4 TOTAL Unique Unique Unique Unique Type IDs Episodes IDs Episodes IDs Episodes IDs Episodes TOTAL 631 4,588 871 9,515 9 40 1,511 14,143 Remedy BPCI Partners, LLC 142 1,602 486 5,243 628 6,845 Genesis Care Innovations LLC 32 1,217 32 1,217 Liberty Health Partners LLC 59 911 49 130 108 1,041 NaviHealth, Inc. 63 738 63 738 Avamere Health Services 31 615 31 615 Optum 17 595 17 595 Access Innovations LLC 13 347 13 347 No Convener 46 126 26 158 8 39 80 323 HCA Management Services, LP 14 259 14 259 Post Acute Care Network, LLC 10 210 10 210 Premier, Inc. 66 162 66 162 Che Trinity Incorporated 15 149 15 149 Medsolutions, Inc. 8 140 8 140 National Healthcare Corporation 15 135 15 135 Signature Medical Group, Inc. 58 126 58 126 Steward Integrated Care Network, Inc., Geisinger Clinic 8 95 8 95 Advanced Home Care 12 87 12 87 Golden Living (Ggnsc Administrative Services, LLC) 5 86 5 86 Mary Washington Health Alliance, LLC 2 86 2 86 Sante Operations, LLC 7 84 7 84 Ensign Service, Inc. 19 55 19 55 Plum Healthcare Group, LLC 24 54 24 54
Phase II Episodes by Period of Performance Begin Date 5000 4500 4000 Performance Begin Date important for Model 2 & 3 Precedence 3500 3000 2500 2000 1500 1000 500 0 10/1/2013 1/1/2014 4/1/2014 7/1/2014 10/1/2014 1/1/2015 4/1/2015 7/1/2015 10/1/2015 Model 2 48 249 3 2 21 213 995 1336 1721 Model 3 21 647 6 21 622 3693 4505 Model 4 1 34 1 3 1 Model 2 Model 3 Model 4
Phase II Episodes by Episode Length 100% Post Acute Episode Length Selections 90% 80% 70% 60% Model 2 50% 40% 30% 20% 10% 0% Model 2 & 3 STAC PGP SNF LTAC IRF HHA 30 Day 60 Day 90 Day Model 3
BPCI Activity: Wisconsin
16 14 12 10 8 6 4 2 BPCI Activity: Wisconsin MODEL 2 MODEL 3 TOTAL Type Unique IDs Episodes Unique IDs Episodes Unique IDs Episodes STAC 1 1 1 1 PGP SNF 14 179 14 179 HHA IRF Total 1 1 14 179 15 180 Participants 200 180 160 140 120 100 80 60 40 20 Episodes Wisconsin ranks 15th in the country in Phase II SNF episode participation 0 STAC PGP SNF HHA IRF 0 STAC PGP SNF HHA IRF Model 2 Model 3 Model 2 Model 3
BPCI Activity: Wisconsin Episode Frequency Major joint replacement of the lower extremity Congestive heart failure Revision of the hip or knee Acute myocardial infarction Simple pneumonia and respiratory infections Chronic obstructive pulmonary disease, bronchitis, asthma Fractures of the femur and hip or pelvis Pacemaker Lower extremity and humerus procedure except hip, foot, femur Stroke Sepsis Esophagitis, gastroenteritis and other digestive disorders Coronary artery bypass graft Medical non-infectious orthopedic Hip & femur procedures except major joint Cellulitis Transient ischemia Percutaneous coronary intervention Medical peripheral vascular disorders Removal of orthopedic devices Syncope & collapse Back & neck except spinal fusion Urinary tract infection Major cardiovascular procedure 0 1 2 3 4 5 6 7 8 9 10 Model 2 Model 3
BPCI Activity: Wisconsin Post Acute Episode Length Selections 100% 90% 80% 70% 60% 50% Model 2 Model 3 40% 30% 20% 10% 0% STAC PGP SNF HHA IRF 30 Day 60 Day 90 Day
BPCI and CJR Activity Shaded Territorie s Represen t CJR MSAs BPCI Participants
Types of Analytics
Data Overload. CMS 2009-2012 Claims Data CMS Monthly Claims Data Alabama 38 Baseline Target Price Trend Factors Applied Current Performance vs. Target Price 29
Questions That Data Helps To Answer ❶ Who else in our market is doing Bundled Payments? ❷ Where are Beneficiaries/Patients going after leaving our facility? ❸ How can we reduce utilization of services and prevent bad stuff from happening during the period of our responsibility? ❹ How can we engage and integrate other providers to work with us on our bundled payment? ❺ What does the financial model look like? Regardless of financial gain/loss, what value do we place on learning and development?
❶ Who else in our market is doing Bundled Payments? Who Else? Precedence Model 4 Presence Trumps Model 2 and 3 Risk Bearing Performance Period Earlier CE-PoP trumps later CE- Pop (Not applicable in Model 4) Encourages early adoption, broad implementation, and partnerships between various providers Models 2 and 3 With Same Performance Period Model 2 Trumps Physician Group Model 2 and 3 PGP Initiator Trumps Non PGP Initiator Attending PGP Initiator Trumps Operating PGP Initiator
Precedence Has a Big Impact Precedence Rules Model 4 Models 2 & 3 Earlier or Same CE-PoP Later CE-PoP Later admission Earlier admission Model 2 Model 3 Model 2 Model 3 Attending PGP Attending PGP Attending PGP Attending PGP Operating PGP Operating PGP Operating PGP Operating PGP Non PGP (Hsp, SNF,IRF, HH, etc) Non PGP (Hsp, SNF,IRF, HH, etc) Non PGP (Hsp, SNF,IRF, HH, etc) Non PGP (Hsp, SNF,IRF, HH, etc) 32
Listing of Wisconsin Activity 33
❷ Where are Beneficiaries/Patients going after leaving our facility? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Discharge, First Destination Q1 2013 Q2 Q3 Q4 Q1 2014 Expired IRF/LTCH SNF HHA Self Care First Discharge Setting (MS-DRG 470) Sample Hospital Av Episode Cost Home (Self Care) $18,135 Home Health Agency Skilled Nursing Fac. Inpatient Rehab Fac. $17,505 $32,189 $35,037 Encourages use of lowestacute post-discharge setting; IRF and SNF are hardest hit
Care Pathways Care Pathways illustrates the specific pathway of care of each episode and its effect on overall episodic spending and ultimately estimated profit/loss.
Post Acute Summary Understanding that their may be PAC services downstream of the first PAC setting, the post acute summary creates a picture of average spend per admit by type of setting and specific provider. SNF, HHA, IRF, and LTACH providers are organized by type and compared to the average spend of their type and how many total dollars are being spent at each facility for complete episodes.
❸ How can we reduce utilization of services and prevent bad stuff from happening during the period of our responsibility? Percent of Episodes that achieved target price ( 97% of historical price) Home 95% 150/158 Home Health 93% 95/102 SNF 41% 47/116 IP Rehab / LTACH 13% 8/61 Total 69% 300/437 Percent of Episodes that missed target price (>97% of historical price) 5% 8/158 7% 7/102 59% 69/116 87% 53/61 31% 137/437 Met, Missed Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provide
Operating Physician Summary The Operating Physician Summary provides analysis of episodic spending by Operating Physician found on the Anchor Hospital record. This report also contains key metrics on each physician, illustrating how readmissions affect their episodes and how often these readmissions may occur after the patient leaves the anchor stay associated with specific physicians. This is also available by Attending Physician.
Physician Discharge Trends Physician Discharge Trends (available for both Attending and Operating Physicians) looks at the discharge destination trend of each physician and the effect of that PAC setting on total episode spending and estimated profitability.
❸ How can we reduce utilization of services and prevent bad stuff from happening during the period of our responsibility? With Negative Event: (Percent of Episodes that achieved target price) Without Negative Event (Percent of Episodes that achieved target price) Readmissions 10% 3/30 73% 297/407 ER Visits 35% 23/65 74% 277/372 Preventable Complications 42% 80/192 90% 220/245 Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provider
Readmission Summary Readmission Summary allows you to monitor the readmission % by month and understand how these readmissions may affect overall episodic spending and estimated profit/loss.
Readmission Detail Readmission Detail is a detailed listing of every readmission in the current data file. The graphs summarize these readmissions by acute care facility, allowing the user to analyze how many readmission dollars are being spent at each facility, both in total and per readmission. The listing gives key information relating to the readmission such as episode, readmitting DRG, payment amount, and day of episode in which the readmission occurred.
❹ How can we engage physicians with our bundled payment? and integrate other providers to work with us? Total Gainsharing not to exceed 20% of Historical Episode Spending Physician Gainsharing capped at 50% of Part B Professional fees Identifying Preferred Providers Episode Count Avg. Episode Payment % of Episodes with Readmit. % of Episodes with ER Visit SNF A 53 $34,406 15.1% 1.9% SNF B 43 $27,969 6.3% 1.3% Frequently use upside-only gainsharing contracts with partners SNF C 24 $30,232 8.3% 4.2% SNF D 20 $37,388 25.0% 15.0% Encourages consolidation around high-quality post-acute providers; can still give Beneficiary choice Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provider
❺ What does the financial model look like? Regardless of financial gain/loss, what value do we place on learning and development? Financial Model Low-Risk Learning Opportunity Expenses Revenues
Millions Why CJR? $12.299 Billion Total Episode Spending $343 Million Savings to Medicare 2.8% Overall CJR Savings to Medicare Medicare s 5-year CJR Financial Est. $150 $120 $127 $100 $71 $50 $35 $11 $23 $30 $52 $55 $0 -$11 ($58) -$50 ($101) ($172) -$100 ($182) -$150 -$200 2016 2017 2018 2019 2020 Losses Collected by Medicare from Hospitals Medicare Gains Distributed to Hospitals Net Medicare Impact 45
Major Policies in CJR that did not change Hospitals are singularly responsible for CJR risk. IPPS hospitals in CJR selected MSAs are mandated to participate. Non CJR hospitals may not opt-in. No downside in first performance year. Applies only to Medicare FFS beneficiaries. Bundle includes IP stay plus 90-days post-discharge. Bundles are retrospective, not prospective. BPCI still trumps CJR for risk delegation. Hospitals may share gains and/or losses with CJR collaborators. Target prices are rebased every other year. 46
Summary of major CJR changes ❶ CJR start delayed to 4/1/16; truncated first year ❷ Moving forward with 67 MSAs; 8 MSAs removed ❸ Quality performance calculations changed dramatically ❹ Hip fractures assigned a unique target price ❺ Stop-loss & stop-gain limits narrowed ❻ More clarification on requirements when sharing gains/losses with collaborators ❼ CMS actuaries expect greater savings in final rule ($343M vs. $250M) ❽ Availability of data to hospitals will be expanded 47
Phasing-in of Regional Pricing 48
Moving forward with 67 MSAs; 8 MSAs removed 789 impacted CJR regional hospitals in 67 MSAs 67 of 789 (8%) CJR hospitals are already in BPCI for LEJR IPPS hospitals in the selected MSAs are required to participate in CJR. Census Region still determinant of regional pricing. Only exceptions are: BPCI Phase 2 LEJR hospitals Non-IPPS hospitals Maryland hospitals Removed MSA Mandated MSA
67 selected MSAs by average episode payments
Zoom-in on 2016 performance year Complications still being measured for PY1 through 3/31/16. Performance Year 1 looks like 9 months, but will only include approximately 6 months of cases. An episode must be initiated after 4/1/16, and the episode, including 90-day post-discharge period, must conclude on or before 12/31/16. 1 st / 2 nd gainsharing distribution from CMS in 2Q 2017. Baseline has already been established. HCAHPS still being measured for PY1 through 6/30/16. Only 2 months of VPRO reporting 1 st / 2 nd reconciliation report in March 2017 / 2018. Download the full 5-year timeline document from www.dhgllp.com/bundledpayments. 51
Quality measures changed dramatically 1. Plot performance percentile for Complications. Example performance: 65 th %ile 2. Plot performance percentile for HCAHPS. Example performance: 25 th %ile 3. If improved 3 deciles from previous year on either measure, add improvement points. Example performance: complications improved from 32 nd to 65 th %ile 4. If voluntary data submitted, add voluntary data submission points. Example performance: yes, submitted data 5. Sum the points. ❶ + ❷ + ❸ + ❹ = 7.75 + 0.00 + 1.00 + 2.00 = 10.75 THA/TKA Complications HCAHPS Survey 90 th 10.00 8.00 80 th and < 90 th 9.25 7.40 70 th and < 80 th 8.50 6.80 ❶ 60 th and < 70 th 7.75 6.20 50 th and < 60 th 7.00 5.60 40 th and < 50 th 6.25 5.00 30 th and < 40 th 5.50 4.40 < 30 th 0.00 0.00 ❸ 3 Decile Improve.? 1.00 0.80 THA/TKA Voluntary PRO and limited risk variable data ❹ Yes 2.00 No 0.00 ❷ 52
Quality measures changed dramatically Effective Discount Percentage Composite Quality Score Quality Category Reconciliation Eligible? Quality Incentive Eligible? Gains (All Years) Losses (Year 1) Losses (Year 2-3) Losses (Year 4-5) < 4.00 Below Acceptable No No N/A N/A 2.0% 3.0% 4.00 and < 6.00 Acceptable Yes No 3.0% N/A 2.0% 3.0% 6.00 and 13.20 Good Yes Yes 2.0% N/A 1.0% 2.0% >13.20 Excellent Yes Yes 1.5% N/A 0.5% 1.5% Impact of 1% reduction in target price is $25,000 per year for a hospital performing 100 CJR procedures per year. 53
Tools for Today: Quality Measures Quality Measure Your Score Percentile Quality Performance Points Quality Improvement Points Quality Composite Score Quality Category Eligible for Reconciliation Payment Eligible for Quality Incentive Payment Effective Discount Percentage for Reconciliation Payment Hospital-level RSCR following elective primary THA and/or TKA (NQF #1550) 2.4 93 10.00 0.00 10.00 HCAHPS Survey measure 3.44 60 6.20 0.00 6.20 THA/TKA voluntary PRO and limited risk variable data submission NO 0.00 0.00 TOTAL 16.20 Excellent Yes Yes 1.50% 54
Hip fractures assigned a unique target price Partial hip replacements are still part of CJR, but will be given its own target prices by MS-DRG Hospital will have four concurrent target prices: MS-DRG 470 w/o fracture MS-DRG 470 w/ fracture MS-DRG 469 w/o fracture MS-DRG 469 w/ fracture Hip fracture is identified by ICD- 9-CM code as the principal diagnosis on the anchor hospitalization claim Statistics from Sample Hospital, 2011-2013 Adjusted Spend per Episode % of total MS-DRG 470 episodes 90-day Readmission Rate MS-DRG 470 without hip fracture MS-DRG 470 with hip fracture $24,431 $41,361 88% 12% 9.1% 27.5% Hospital ALOS 3.1 days 6.0 days % discharged to SNF % discharged to Home Health 35.8% 84.6% 59.1% 7.8% 55
Big Data: Hip fracture policy change is significant Primary Procedure % of 2011-2013 Episodes Average Episode Payment Total knee 58.3% $23,275 Total hip 29.9% $24,280 Partial hip 11.1% $39,272 Total ankle 0.4% $20,166 Admission Type % of 2011-2013 Episodes Average Episode Payment Elective 83.1% $23,427 Emergency 9.9% $39,168 Urgent 6.3% $28,414 Trauma 0.3% $38,685 Other 0.4% $25,252 Hip fractures commonly: Result in partial hip replacement procedures. Are emergent or trauma admissions. These tend to be much more expensive episodes of care. Source: DHG Healthcare and Dobson DaVanzo & Associates research using CMS Public Use Files 11-13 56
Clarified gain/loss sharing requirements Provided a lot more clarity and specificity on PGP gainsharing PGPs must have distribution arrangement with members Gainsharing funds must not be placed in PGPs general funds Hospital must include quality measures in collaborator selection and distribution method CJR Collaborators must be listed on the hospital s website, updated quarterly Gainsharing arrangements must be entered into before care is furnished to CJR beneficiaries SNF LTCH Physician Group Practices Nonphysician practitioners HHA IRF Physicians Outpatient therapy providers 57
Medicare CJR Data Data availability expanded significantly Data will be made available no less frequently than on a quarterly basis with the goal of making these data available as frequently as on a monthly basis if practicable. Hospitals must request data one time, not recurring. Beneficiaries may not opt-out of sharing their data with the CJR hospital. Alcohol and drug abuse patient records will not be shared. Hospital Claims-Level Hospital Summary Census Region Aggregate 58
Tools for Today: Provider Intelligence STAR Ratings First PAC Episode % of Ep. w/ Count Readm. ALOS First PAC Spend Total Episode Spend Quality Staffing Nursing Staff Health Insp. Overall Total SNF 288 12.6% 19.8 $9,375 $31,600 ALPHA SKILLED NURSING-123456 174 12.2% 16.0 $7,819 $31,197 5 4 4 3 5 CITY SKILLED NURSING-124567 42 15.0% 21.1 $10,100 $33,355 3 4 3 5 2 GOLDEN SKILLED NUR-125678 17 7.1% 16.5 $7,622 $28,221 3 4 4 1 2 ALL OTHER (18) 55 14.0% 29.0 $14,461 $36,788 Identify the same information for Home Health (HHA), Inpatient Rehab (IRF), and Long-Term Acute Care Hospitals (LTACH) 59
Big Data: A patient s care path after discharge matters a lot Pathway % of Episodes Episodic Spending Estimated Target Price Per Case Profit/(Loss) Acute HHA 28% $19,341 $25,000 $5,659 Acute SNF 19% $27,752 $25,000 ($2,752) Acute SNF HHA 14% $31,879 $25,000 ($6,879) Acute HHA Readmit. 13% $38,696 $25,000 ($13,696) Acute Readmit. 10% $26,626 $25,000 ($1,626) Acute SNF SNF HHA 6% $50,005 $25,000 ($25,005) Acute SNF HHA Readmit. 5% $48,506 $25,000 ($23,506) Acute HHA Readmit. HHA 5% $36,545 $25,000 ($11,545) Source: DHG Healthcare and Dobson DaVanzo & Associates research using CMS Public Use Files 11-13 60
CCJR: SNF Scorecard 61
LEJR Episodes are Not Normally Distributed Typical Episode $25,000 Bundle Busters
Strategies for Now Develop gainsharing protocols for orthopedic surgeons Enhance episodic care management Assess opportunity for internal cost savings (ICS) Prepare for ongoing data analysis throughout CJR implementation Focus heavily on post-acute Identify quality performance and prepare for voluntary PRO reporting 63
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