ccjr: early lessons from the provider community...•5-star nursing home compare rating now...

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Zimmet Healthcare Services Group, LLC

Innovation in Reimbursement

August 17 - 18, 2016

CCJR: Early Lessons from the Provider Community

August 17 – 18, 2016 Atlantic City, NJ

HHS Payment Reform

• HHS Secretary Burwell: “Target to increase the number of payments that are linked to quality outcomes by 2018”

– Goal #1: 30% of all Medicare provider payments to be in alternate payment models tied to quality by 2016; 50% by 2018

– Goal #2: Virtually all Medicare fee-for-service payments to be tied to quality and value; 85% in 2016 and 90% in 2018

Value-Based Purchasing

• Goal for 30% value-based purchasing achieved 11 months early

– Largely due to ACO and Bundled Payment expansion

– Aim to continue increase to 50% by 2018 through CJR bundled project starting April 1, 2016, and New Episode Based Payment Models starting July 1, 2017

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August 17 - 18, 2016

Bundled Payments for Care Improvement

• Incentivize providers to reduce cost of episode against a target cost by coordinating acute and post-acute care

• Align incentives by providing opportunity to share gain in cost savings

• 48 DRGs which represent the clinical condition of approx. 70% of Medicare spending

• Organizations enter into arrangements that include financial and performance accountability for episodes of care

• Four models: – Model 2: Acute, Post-acute, readmission – Model 3: Post-acute and readmission

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Bundled Care Initiative

• Early results for Models 2 - 4

– Small sample size but…….

• Hospitals less likely to refer to SNFs and relied on home health agencies to reduce costs

• The Part A payment to SNFs and days billed significantly decreased for SNF and increased for HHA

BPCI Round 2

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BPCI Model

Round 1 January 2013

Round 2 June 2014

Model 1 21 15

Model 2 688 2,043

Model 3 1,895 4,514

Model 4 23 12




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August 17 - 18, 2016

New Episodic Payment Models

• CMS Proposal for New Conditions

– Acute Myocardial Infarction (AMI)

• DRGs 280-282 and 246-251

– Coronary artery bypass graft (CABG)

• DRGs 231-236

– Surgical hip/femur fracture treatment (excluding lower extremity joint replacements (SHFFT)

• DRGs 480-482

New Episodic Payment Models

• 5-year models (July 1, 2017 – December 31, 2021)

• Retrospective payment system

• Episode includes hospital admission and 90 days post discharge

• AMI and CABG Bundles mandatory in 98 randomly selected MSAs

• SHFFT expanded to same 67 CJR MSAs

The Comprehensive Care for Joint Replacement Payment Model

• Proposed rule to test Bundled Payments

• 5-year model

• 67 Geographic regions

• Hospital responsible for costs of Hip and

Knee replacement surgery through 90 days

after discharge




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August 17 - 18, 2016


• As opposed to BPCI where participation is voluntary,

this model requires providers to participate

• Why Lower extremity replacements?

– High expenditure ($7 Billion/year), high utilization

procedure (430,000/year)

– Wide Variation in spending among Post Acute Providers


• Model includes MS-DRGs 469 and 470

– Both With and Without major complications

• Episode would include procedure, inpatient stay, and related

care covered under Medicare Part A and B within 90 days

after discharge including PAC

• Current payments methodology would be unchanged;

retrospective calculation of actual episode payments

CJR Utilization




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August 17 - 18, 2016

AHA Initial Comments

September 2015

• The industry as a whole needs more time to prepare

• Request for waiver to Anti-Kickback Statue and Physician Self Referral Law

• Allow hospitals to form financial arrangements with other providers and to allow a limitation on post- providers

Hospital Survey

Survey of over 100 hospital representatives regarding readiness for CJR (January 2016):

1. How prepared is your hospital for CJR?

– Only 9% responded would be fully prepared

2. What is your goal date for fully implemented CJR program?

– 56% responded after April 1, 2016

3. What investments are you making for CJR?

– 75% hiring staff to mange bundle patients (navigator/coordinator)


• Actual episode payment would be compared to established target cost after performance year

• If episode cost is below target, hospital is paid the difference (reconciliation payment)

• If episode cost is above target, hospital is responsible to repay difference (repayment would start after year 2)

• Bonus/Penalty Ceiling and Floors to limit risk – Stop loss policy in place




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August 17 - 18, 2016


• Target price then blended between hospital and regional average costs and updated each year

• Regional comparison to one of 9 US census divisions

• 2% Medicare savings/discount applied to target


• Initial Target Price based on 3 year historical data:

Performance Year(s)

Historical Date Range

Hospital Portion

Regional Portion

1 and 2 Jan 1, 2012-Dec 31,

2014

2/3 1/3

3 and 4 Jan 1, 2014- Dec 31,

2016

1/3 2/3

5 Jan 1, 2016-Dec 31,

2018

N/A 100%




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August 17 - 18, 2016

Reconciliation Forecast

“Initial studies show that up to 60% of participating hospitals currently

have an episodic cost higher than the regional average”

*Avalere March 30, 1016

Hospital Target Price Pressure

NYU DRG Payment

Average SNF

payment

Total Acute + SNF

Episode Cost

Middle Atlantic Regional Historical Average

DRG 469 $32,815 $20,086

(28 days @ RUB)

$52,901 $52,028

DRG 470 $21,290 $10,043

(14 days @ RUB)

$31,333 $27,406

CJR Spend




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August 17 - 18, 2016

Stop Loss/Gain

Performance Year Stop Loss Stop gain

1 NA 5%

2 5% 5%

3 10% 10%

4 20% 20%

5 20% 20%

Hospital Quality Measures

• Hospital can only receive reconciliation payment is

the score well on the following Quality Measures:

– Complication measure

– Readmission measure

– Beneficiary experience survey measure (HCAHPS)

• All 3 have PAC implications

Data Sharing

• Directly with Hospitals

– Detailed and summary level claims data for Part A and B

– 3-year Historical claim history at the start of CJR

– Quarterly data including episode claim data and aggregate regional claims data

– Initial quarterly report was

due end of July.



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August 17 - 18, 2016

SNF Implications and Keys Factors

The Proactive Approach to Success under CJR

Opposing Incentives

• SNFs still paid on the current PPS system; RUGs, LOS still matter to bottom line

• But acute care partners will rely on PAC partners to curb episodic spend

• Cost-Benefit analysis by admission

• DO NOT arbitrarily change operations without expectation to maintain or expand referrals

Short Stay Dilemma

• 5-day vs. 6-day Clinical Protocols

* Scheduled discharge date

Medicare Day 1 2 3 4 5*

Date 8/1 8/2 8/3 8/4 8/5

Therapy Minutes 120 120 120 120 0





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August 17 - 18, 2016

Short Stay Dilemma

• Can’t do Short Stay (> 4 days from start of rehab)

• Surgical wound = CC1 @ $362/day vs. anticipated RUB @ $717/day

• Therapy Charge = $138/day ($1.15/minute)

• Could have started on Day #2 (Short Stay applies) or provide 20 minute training on day of discharge to capture RVB

Marketing Analysis

• Use of publically available data from CMS to:

1. Evaluate market referral patterns (number of referrals, percentage of referrals from each acute care facility)

2. Determine how your performance compares to competition (Medicare ALOS, Medicare episodic cost, re-hospitalization rates, 5-star rating)

3. Develop “Angles” to Market for referrals

Preferred Provider Concept

• Hospital likely to determine based on following criteria: 1. Risk-adjusted readmit rate

2. CMS quality measures

3. Staffing

4. Patient complaints

5. Processes and outcomes

6. Compliance and government surveys

• Ongoing analysis of key performance indicators to determine inclusion




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August 17 - 18, 2016

Provider Questionnaire • Medicare FFS ALOS

• Managed Care ALOS

• Days per month Medical Director visits SNF

• Onsite Specialty Consultants (Psych, Wound Care, Resp Tx)

• Nursing Hours/Day, Staff turnoff %

• Use of Interact tools

• Any Care Transition post-discharge

• In-house or outsource therapy, day/week of therapy, use of FIM/outcomes tests

• Clinical/medical management (IVs, Trach/Vents, Dialysis)

• Readmission Rates (short vs. long-term residents)

• If SNF would commit to use of network preferred HHA

Care Coordinators

• NaviHealth

– PAC management contracted by hospital

– Aim to reduce PAC utilization variations

– Utilize proprietary software to predict beneficiaries recovery capacity

– Recommend care setting and PAC utilization levels

• Remedy Partners

– “The Episode of Care Company”

– Utilizes ‘Episode Direct’ Analytics Program

Post Acute Care Coordinators

• NaviHealth Process 1. Admission to Facility

2. Initial clinical documentation (Day 2-3 post admission)

3. LiveSafeOPT (Outcome Prediction Tool) report sent to Facility

4. Clinical update every 7 days following admission

5. Updated LiveSafeOPT report sent

6. Patient Discharge

7. Discharge documentation submitted 2 - 3 days post-discharge




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August 17 - 18, 2016

LiveSafeOPT

• Indicates the following:

– Admission scores

– Impairment and Diagnostic Groups

– Estimated length of stay (“ELOS”)

– Therapy hours per day

– Projected DC scores

– Likelihood of Discharge Setting

– Recommendations

– Placement Decisions

Performance Dashboard

What It Means to You

• Need to understand the Tools directing the decisions

– Need to address Cognition

• Who’s making treatment/therapy decisions

– NaviHealth feels that residents generally get better with

540-575 minutes per day

• Who’s making discharge decisions

• Relationship/communication with care coordinators

• Impact on future referral (census maintenance)

– Conveners will use outcomes to direct future referral

patterns

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August 17 - 18, 2016

Collaborators

• Collaborators for gainsharing arrangements could be with PAC providers including SNFs

• Must engage in care redesign strategies to be eligible for gainsharing; can have two-sided risk

• Hospital must retain at least 50% repayment risk with CMS, can’t share more than 25% with any one collaborator

Re-Hospitalizations

The 800-pound Pink Elephant in the room!

• SNF must have clinical programs and protocols in place to reduce readmissions (use of NP/PAs) and re-hospitalizations (post-discharge follow-up).

• Emphasis should be placed on clinical assessments and interventions prior to ER discharge, avoiding premature discharges, and communication between patients, caregivers and providers

• Use of Technology for “Care Transitions” to ensure post-discharge compliance

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CJR Readmission




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August 17 - 18, 2016

Telehealth

• New incentive for hospitals to provide follow-up services post discharge

• Waiver for both patient geographic and originating site requirements

• New G-codes to report home telehealth visits furnished to CJR beneficiaries

• These patients lend themselves to this form of monitoring as the clinical condition typically without cognitive impairment, age range 65 - 75 and without significant co-morbidities in most cases

SNF 3-Midnight Waiver

• Waiver for SNF 3-day hospital stay to a discharge SNF with at least a 3 star rating.

• Begins Year 2 of Program

• SNF will only get the more acute and complex cases

• 5-star Nursing Home Compare rating now significantly impacts discharge decisions

• Now Annual survey and Nurse staffing imperative to financial success

New Quality Measures

• Five of six will be phased into 5-star Quality Ratings system over a 9-month period

• Only the measure on anti-anxiety or hypnotic medication not used

• Benchmark data will be a year of information up to July 2015




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August 17 - 18, 2016

New Quality Measures

• Claims Based Data 1. % of Short-stay that have ER visits 2. % of Short-stay discharged to community (and remained

home for 30 day post-d/c) 3. % of Short-stay re-hospitalized after SNF admission

(includes observation)

• MDS Based Data 1. % of Short-stay that made improvements in physical

functioning and locomotion 2. % of Long-stay that ability to move independently

worsened 3. % of Long-stay that received an anti-anxiety or hypnotic

medication

Success Under Bundling

• Investigate current market dynamics and where your SNF “fits in”

• Engage hospital with proactive clinical initiatives

• Analyze data specific to your utilization patterns

• Know your key metrics (SNF Episodic Costs, ALOS, 5-star rating, readmission rate)

• Develop integrated care transition programs

• Monitor and report outcomes

Conclusion

• Pressure to have and promote quality outcomes

–Aggressively market and develop preferred partner relationships

–Demonstrate a focus on reducing readmission rates

–Maintaining (at least) a 3-star rating is key




ccjr: early lessons from the provider community...•5-star nursing home compare rating now...

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