New Models in Payment: Joint Replacements Sharon Eloranta, MD February 18, 2016
Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington Medicare.QualisHealth.org 2
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Ambitious Goals to Link Payment to Performance 100% 80% 60% 40% 20% 0% Percent of Medicare Payments Tied to Quality or Resource Use 30% 50% ACOs or Bundled Payments 2016 2018 85% 90% Traditional FFS Medicare 4
Bundled Payment of Care Initiatives https://innovation.cms.gov 5
Value-Based Purchasing: Expanding Dollars at Risk and Number of Eligible Providers Provider Type FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 PPS Hospitals 2% 3.25% 5.5% 5.75% 6% 6% 6% Physicians - - 2% 2% 4% 4% 4% ± SNFs - - - - - - 2% HHAs - - - - - 3%* 3%* *Pilot in 9 states, including WA ± Physicians not participating in Alternative Payment Models (APMs) 6
Value-Based Purchasing: Expanding Dollars at Risk and Number of Eligible Providers 2% cut for all CMS redistributes this $, based on performance VBP for hospitals is revenue neutral; CMS designed NH program to save $ Most SNFs will lose some $ 7
FY 2019 SNF VBP Just One Measure: All-Cause Rehospitalizations within 30 Days of Acute Care Discharge 2015 2016 2017 2018 2019 Baseline Period Performance Period Payment Adjustment 8
VBP: Next Evolution Measure to be replaced as early as FY 2020 from all-cause readmission to preventable rehospitalization Measure currently undefined 2014 MedPac study bases definition on specific diagnoses 9
What s Preventable? Per MedPAC: Adverse drug reactions Anticoagulant complications Blood pressure management Cellulitis/wound infection Delirium Electrolyte imbalance/dehydration Fractures, musculoskeletal injuries Heart failure Hypoglycemia/diabetic complications Pressure ulcers Respiratory illness/bronchitis/pneumonia Sepsis Urinary tract and kidney infections 10
Preventable SNF Readmissions Source: Medicare claims; includes all hospital readmissions, planned and unplanned. Not risk adjusted. 11
CJR: Hips and Knees Take Center Stage Effective April, 2016 Mandatory participation in selected areas Seattle (Snohomish, King, Pierce Counties) Portland (includes Clark County) Targets two frequent, profitable and potentially costly procedures: TKA and THA 90-day payment episode 12
800+ Hospitals Nationwide 13
90-Day Payment Episode All Inpatient Costs Includes Physician Costs and Part B drugs All Post-Acute Costs for 90 Days: SNF costs Readmission costs Rehab costs, DME Physician costs HHA costs LTAC costs 14
Retrospective Reconciliation Places Onus on Hospital All providers paid normally; at the end of each year, hospital either receives bonus from CMS or is required to repay the difference from the target price 15
How is the Target Price Set? Year 2016 2017 2018 2019 2020 Formula Hospital- Specific Regional Hospital- Specific Regional Hospital- Specific Regional Regional Regional Baseline 2012-2014 2014-2016 2016-2018 16
Interesting Program Waivers SNF Waives 3-day rule starting in year two SNF must be 3 stars or above to qualify Home Visits CMS pays for up to 9 home visits by clinical staff per episode Distinct from Home Health 17
Implications of CJR Post-acute care will be under scrutiny: Hospitals have financial incentive to optimize referrals Increased need for data: All players will need data: LOS, readmission rates, complications, service provision All rehospitalizations matter - not just 30 day Patient selection 18
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Positioning for Success Now Understand your data Form partnerships, improve communication Create cross-setting care paths Involve physicians in all settings Opportunity for SNFs: Home to Stay Collaborative 20
Bree Update: Bundles and Warranties Payment Entire episode of care Potential complications from poor care Thanks to Ginny Weir at FHQC and Dr. Bob Mecklenburg at VMMC for this material 21
Bree Collaborative recommendations include: Hospital readmissions Obstetrics Joint replacements Spine surgery (fusions) Cardiology Low back pain End of life care Addiction and dependence treatment (working on: bariatric bundle, opioid use, AP in children) 22
Paying for Value: Accountable Care Networks for Washington State Public Employees New health benefit starting 2016 Available networks: Puget Sound High Value Network LLC UW Medicine Accountable Care Network www.hca.wa.gov/hw/documents/acpfactsheet.pdf 23
Expanding HCA s Bree Implementation Efforts Healthier WA paying for value Test Model 3 In 2017, invite other large purchasers to join HCA s effort Expand geographic coverage of HCA s ACP effort statewide 24
Knee & Hip Procedures http://www.breecollaborative.org/wp-content/uploads/bree_summary_chars_analysis.pdf 25
A Warranty for TJR Aligning payment with safety A contract between provider and purchaser/payer whereby Provider will correct failure of their product At no additional cost to purchaser 26 26
Warranty General Content Complications included in warranty 1. Significant complications attributable to procedures 2. Identifiable in administrative claims data 3. Fair to hospitals and physicians 27
Specifics of Warranty Adults with TJR for Osteoarthritis Periods of accountability are complication-specific and apply to readmission to the hospital where surgery was performed. 7 days a. Acute myocardial infarction b. Pneumonia c. Sepsis 30 days a. Death b. Surgical site bleeding c. Wound infection d. Pulmonary embolism 90 days a. Mechanical complications related to surgical procedure b. Periprosthetic joint infection 28
Bundled Payment Model Aligning payment with quality 29
Bundle: Four Components 1.Document disability despite conservative therapy (appropriateness) 2. Ensure fitness for surgery (safety) 3.Provide all elements of high quality surgery (surgical) 4. Facilitate rapid return to function And transparent quality metrics 30
Cycle #1: Disability An Appropriateness Standard 1. Measure disability on standard scale: HOOS/KOOS 2. Measure osteoarthritis on standard imaging scale: Kellgren-Lawrence 3. Provide explicit evidence-based conservative therapy for at least three months unless disability and x-ray findings severe 4. Document failure of conservative therapy on HOOS/KOOS 31
Cycle #2: Fit for Surgery A Safety Standard Physical preparation and patient engagement 1. Standards relating to patient safety 2. Patient engagement: shared decision-making 3. Designated care partner to assist patient throughout course 4. Standard preoperative evaluation includes nasal culture and screen for delirium 32
Cycle # 3: Surgery A surgical quality standard a. Minimum annual volume for surgeon b. Multimodal anesthesia c. Avoid infection d. Avoid bleeding/low BP e. Avoid thromboembolism f. Maintain optimal blood sugar g. Selection of surgical implant 33
Cycle #4: Recovery Rapid Return to Function standard Standard processes in place at facility where surgery performed 1. Standardized post-op care in the hospital 2. Discharge process from WSHA/Alliance/Qualis Health tool kit 3. Standardized disposition planning 4. Standardized follow-up communication and appointments 5. Measurement of functional outcomes 34 34
Thoughts? What have you heard How are you preparing What do you think the impact will be Care paths? Physician involvement? Other initiatives? 35
Q & A 36
Contact Sharon Eloranta, MD Medical Director, QSI sharone@qualishealth.org 206.288.2474 www.medicare.qualishealth.org/hometostay This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-C2-QH-2131-02-16 37