value based care: comprehensive care for joint ... - 2020...growing market share – physicians...

Value Based Care: Comprehensive Care for Joint Replacement (CJR)

Steven A. Maser, MD, Medical Director Orthopedic SurgeryMina Le Fevre, RN, System Central Nurse Navigator

Atlantic Health System

Meet Our Presenters

Steven A. Maser, MDMedical Director Orthopedic Service Line


Mina Le Fevre, RNSystem Central Nurse Navigator


Patient Flow Summit - September, 2018

Conflicts of interest

Both speakers have received hotel

accommodations from this meeting

complements of CentralLogic. Atlantic Health

System has used the CentralLogic product,

Analytics Explorer, as noted in the presentation.

Neither speaker has any other conflicts of

interest to disclose relative to this presentation.


Headquartered in Morristown, New JerseyNot-for-profit 5 hospital system with 1,747 beds

Children’s, Rehab, Home Care and Hospice600+ community-based health care providers

1.9 Million primary population servedPart of Atlantic Accountable Care Organization



Maintain good physician relationships

Risk shifts to providers

Control costs for

high-cost procedures

Industry Challenge

Hip/knee replacements

most common Medicare

inpatient surgery –

Quality and costs vary

greatly among providers

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

Average Medicare

expense for hip/knee

surgery, hospitalization

and recovery ranges from

$16,500 to $33,000


Comprehensive Care for Joint Replacement (CJR)

Program

CJR

5-year program

began 4/1/16

Mandatory

Beneficiaries Medicare FFS

Beneficiaries DRG’s 469 &

470EpisodeDRG + 90

days post-discharge

Target Prices

Risk on Hospital

Reconciliation Payments

788Expected number of participant hospitals

$343MEstimate of episodic savings

over five years

Source: CMS, The Advisory Board Company


The Episode

Source: The Advisory Board Company


The CJR Program - Target Price

Separate targets are calculated for the following bundles

▪ MS-DRG 469 without fracture

▪ MS-DRG 469 with fracture

▪ MS-DRG 470 without fracture

▪ MS-DRG 470 with fracture

CJR Reconciliation Payment

2016 2017 2018 2019 2020

Stop-

Gain Limit5% of

target

5% of

target

10% of

target

20% of

target

20% of

target

Stop-

Loss Limit0%

5% of

target

10% of

target

20% of

target

20% of

target

Medicare Payment

Below Target Price


The CJR Program - Quality

▪ Quality results $$

▪ Composite Quality Score determines discount

▪ Minimum “Acceptable” score to receive any reconciliation payment

▪ Higher score = less $ for you to pay back to CMS or more to receive

CJR Composite Quality Scoring

Quality CategoryMaximum

Points

Score

AllocationNotes

Complications (RSCR) for

THA/TKA (NQF # 1550)10 50%

Based on hospital’s decile

performance nationally

HCAHPS

(NQF #0166)8 40%

Based on hospital’s decile

performance nationally

PRO Submission 2 10%Voluntary year 1-3, may be

mandatory year 4-5

Meet Composite

Quality Standards


The CJR Program- Recap of Payment

Medicare Payment

Below Target Price

Meet Composite

Quality Standards

Amount of Reconciliation

Payment


Source: Atlantic Health System

Atlantic Health System (AHS)

Hospitals included in CJR


• Total Hip Replacement

• Total Knee Replacement

• Spine Surgery

Morristown Medical Center• 702 beds

• 37,527 annual admissions

• 14,133 annual inpatient

surgeries

• 16,616 outpatient surgeries

• 90,809 emergency room visits

Accolades for Total Joint Replacements


AHS Orthopedic Volume at a Glance

1,700 CJR surgeries annually

4,000 Total joint surgeries annually (including single, bilateral, primary and revisions)

6,000 Inpatient orthopedic annually

12,000 Orthopedic surgeries annually (including in-patient and ambulatory surgeries)


Challenges with Physician Make-Up

…completing fewer than 3% of the

CJR cases are employed physicians,

remainder are independent physicians

Annual CJR Cases

Employed Physicians

Independent Physicians

Source: The Advisory Board Company

Only 2 of the 84 CJR surgeons…


Model Year 1 Constructs

Developed goals and initiatives –

focus on patient discharge

Baseline – processes and metrics

Steering Committee and

Work Groups Established


AHS Senior Leadership

CJR Steering Committee

Clinical Guidelines/Care Re-Design Work Group

PAC (Post Discharge Work Group)

Inpatient Cost Work Group

Financial/Data Work Group

Quality/Outcomes Work Group

CJR Administrative Lead

CJR Orthopedic Chair

Model Year 1 Steering Committee


Baseline Data Provided Key Recommendations

Learn from the leader

and disseminate

best practices

SNF/IRF Review

Physician engagement

Thorough care pathway assessment


Model Year 1 Goals

Increase discharge disposition

to home

Decrease LOS at post-acute care facility (SNF or IRF)


• Standardization of Order Sets System-wide

• Standardization of Care Guidelines

• Standardization of Patient Education

• Development of CJR Preferred Provider List

• Implementation of Patient Risk Stratification

Patient Focused andQuality Driven Standardization

Model Year 1 Initiatives


Hospitals

Importance of Actionable Analytics

Comprehensive performance scorecards

Home care agencies

Skilled nursing partners Surgeons

Custom development

• CJR analytics

• Quantified performance

opportunity by DRG and

fracture status

• Patient satisfaction

• Complication rates

• Readmission reporting

• Cost

• Utilization

• Joint education

Balanced set of measures

Focused on reducing variation

and optimizing post-acute

utilization


Surgeon Scorecard

Sample data

Source: CMS Data Release & Change Healthcare


Baseline Data Review

Physician Performance Report


explorer


Year 1 Orthopedic Surgeon Gainsharing Metrics

DRG 470 without fracture

discharge to home

Risk adjusted complication

rate

Elective patients

participation in education

“joint” class

Completion of pre-surgical

PRO documentation


Key Objectives Developed for the Work Groups








Navigator Work Group

System Central Navigator

MMC Site Navigator OMC Site Navigator CMC Site Navigator NMC Site Navigator


CJR Orthopedic

Chair


CJR Episode Cost

Cost = Acute Care + 90-Day Post- Discharge (including Readmissions)

Low Variation

Minimal cost

savings

opportunities

High Variation

Significant cost

savings

opportunities

44.26% Inpatient Services

16.34% Professional Services

60.6% Total

39.4% Total


Why is Discharge Disposition to Home for

Elective Patients Important?

Increase Discharge

Disposition of Home

Improve Quality

Decrease Likelihood of

Complications

Decrease Readmission

Rate

Decrease Resource

Use


Risk Assessment and Prediction Tool (RAPT)

Measures risk factors

that can interfere with

discharge to home▪ Age group

▪ Gender

▪ How far on average can

patient ambulate

▪ Gait aid used

▪ Community supports

utilization

• Home Help

• Meals on Wheels

▪ Caregiver after surgery


RAPT Limitations

1. Does not account for risk factors such as*

*Currently evaluating a tool for readmissions that will look at these risk factors

Obesity

Diabetes

Smoking

Cardiovascular Disease

Neurocognitive, psychological, and behavioral issues

COPD


Care Navigation

▪ Patient Connect is the Web Based Care Coordination

technology that AHS utilized to capture & centralize data

and clinical information to identify high-risk CJR Patients

through the use of the RAPT Tool and Post Acute Discharge

Disposition to assist the CJR Nurse navigators in:

✓ Reducing 30 Day Readmissions

✓ Improving Patient Satisfaction

✓ Better Managing Population Health

✓ Improving Compliance with Discharge Instructions and

Medications

✓ Increasing Engagement of the Primary Care Team in

care transition process


Care Navigation Work Group

Score <=6

• Increased likelihood of discharge to PAC

• High-Risk tracked by Central Navigator

Score 7-9

• Intervention to discharge directly home

• Medium-Risk tracked by Site Navigator

Score >9

• Increased likelihood discharge directly home

• Low-Risk tracked by Site Navigator

Score <=6RAPT Scoring


Care Navigation Work Group


What did all of this work get us?









System Central Navigator

MMC Site Navigator OMC Site Navigator CMC Site Navigator NMC Site Navigator




Model Year 1 – Physician Report Card



Baseline–Model Year 1 - SNF Mean LOS Trend




SNF per Episode Savings


CJR Year 1 Goals and Successes

Increase discharge disposition to home

117% increase in patients going home

Decrease LOS for patients going to post-acute care

facility (SNF or IRF)

52% decrease in LOS


Year 1 Reconciliation Payment


Model Year 2 Constructs

Focus shifted to reducing readmissions

Year 1 served as baseline data for

more improvement opportunities

Work Groups further developed


Focus for Model Year 2




Pre-AdmissionWork Group

Index Admission Work Group

PAC (Post Discharge) Work

GroupCase Analysis





SNF Report Card



Model Year 1 - Readmissions by Month



Model Year 1 - Readmission Data



What results did we see from the

changes in Model Year 2?

Data source: CMS Data Release

Discharge Home Trend: Baseline vs. Current



AHS CJR Discharge Disposition to HomeDRG 470 w/o Fracture

Chilton Morristown

Newton Overlook



Model Year 3 and Next Steps

Financial

Opportunities

Potential millions in savings

with brand implants

Create CJR patient flags

Develop Healthy Planet

Epic

Implementation

Tracking metrics for case study

Commercial

Bundles

• 24/7/365 nurse assisted

hotline for CJR patients

• 24/7/365 Critical care

response at home

Mobile Integrated Health

Physician choice to

take risk for higher

percentage of

gainsharing

Focus on Pre-op Optimization

Implementation of Readmission Risk

Assessment Tool


Outcomes

Increased efficiency -

Lower cost$10M in Medicare Savings vs.

Target Price

Halo effect – broad changes of physician behavior

Reduced

readmissions

Growing market share –physicians bring cases to AHS for gainsharing

• 117% increase of patients going home

• Significant increase in patient and care

navigation

• Best practice initiatives

• 52% decrease post-acute length of stay

Improving quality

ED observations vs. admission process

Improved hospital throughput

Additional revenue via reconciliation payments of $3.5M


Thank you!

value based care: comprehensive care for joint ... - 2020...growing market share – physicians...

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