Edifecs: Demonstrating who you are in CJR
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The document outlines key aspects of the Comprehensive Joint Replacement (CJR) program, including its structured agenda, cost management strategies, and implications for hospitals regarding participation and financial risk. It highlights the necessity for improved care coordination, data sharing, and alignment between hospitals and clinicians to successfully manage bundled payments and reduce total episode costs. The urgency for hospitals to adapt to these changes before penalties begin is emphasized, alongside the call for evidence-based standardized care practices.
Edifecs: Demonstrating who you are in CJR
- 1. February 24, 2016 Demonstrating Who You Are in CJR: Data Describes the Problem, Providers Deliver the Solution
- 2. © QURE 2016 Agenda • Introduction • CJR review • Cost management strategies • Defining CJR success • Q&A 2 Jay Sultan, Edifecs Principal Strategy Advisor John Peabody, MD, PhD, FACP President, QURE Healthcare Professor, UCSF, UCLA Speakers
- 3. © QURE 2016 CJR Highlights • No choice about participation • Focus on post-acute care • Risk is borne by hospitals • New opportunities for improving care • Mandate to lower total episode costs • Episode impact will not be limited to CJR 3 Critical implications for hospitals
- 4. © QURE 2016 Are Hospitals Prepared for CJR? 4 39% have no experience of managing LEJR episodes 43% just getting started with bundled payments 44% in planning stages to analyse historical data to identify best- performing PAC providers 30% do not know if they will enter into gainsharing with SNFs 30% rely on manual ways to administer gainsharing payment 52% limited data sharing experience with providers 5Top-most challenges faced by providers Tight timelines to prepare Gainsharing program administration Ongoing episode monitoring & reporting Partnership agreements/contracts with providers Care redesign for the entire episode Source: CJR Readiness survey conducted by Edifecs, February, 2016.
- 5. © QURE 2016 CCJR And High Variability in Clinical Practice Costs Select MSA Wage-Adjusted Episode Payments for TKA in CMS’ 9 Target Price Regions • Higher: $32, 060 • Las Vegas- Henderson- Paradise, NV • Lower: $21,1660 • Lake Havasu City-Kingman, AZ • Higher: $28, 219 • Los Angeles- Long Beach- Anaheim, CA • Lower: $18,440 • Napa, CA • Higher: $25,780 • Norwich-New London, CT • Lower: $24,200 • Portland-South Portland • Higher: $33,072 • Miami-Fort Lauderdale-West Palm Beach, FL • Lower: $24,472 • Myrtle Beach-Conway-North Myrtle Beach, SC-NC • Higher: $31,076 • New York-Newark- Jersey City, NY-NJ-PA • Lower: $25,091 • Albany-Schenectady- Troy, NY • Higher: $32,544 • Beaumont-Port Arthur, TX • Lower: $26,123 • College Station-Bryan, TX • Higher: $31,789 • Tuscaloosa, AL • Lower: $26,312 • Evansville, IN KY • Higher: $31,198 • Carbondale-Marion, IL • Lower: $23,052 • Davenport-Moline-Rock Island, IL • Higher:$25,664 • Springfield, MO • Lower: $21,469 • Iowa City, IA Sources: Centers for Medicare and Medicaid Services 5
- 6. © QURE 2016 Variation in Discharge Patterns Hip/Knee replacement facts • Cost of post acute care growing 15%/year and is now greater than cost of actual surgery • 300% variation in nursing home utilization • Discharge patterns vary enormously by regions within states 6 Sources: Definitive Healthcare, 2013 Medicare SAF (1/1/2013 – 12/31/2013) Note: # for every 10 patients rounded to the nearest whole number
- 7. © QURE 2016 Managing Two Cost Structures 7 Managing Hospital’s Own Cost • With or without CJR, all hospitals need to manage this • Focus is on LOS, implantable costs, formulary, readmission • Hard for most hospitals to do more without physician’s cooperation Managing CMS’s Cost • Within the gainloss and gainshare, the hospital earns or loses 100% of CMS’s spend during the post-acute period • Other providers are spending your money • A single patient who is discharged home instead of a SNF could mean thousands of dollars in gained revenue.
- 8. © QURE 2016 Equip Leadership with Analysis of Historical Data to Design the CJR Program 8 • Intake and validate historical CMS episode payment data • Perform episode volume analysis by DRG, LEJR procedure, comparison with regional episode costs • Perform trended and annual inpatient and post- acute provider utilization and cost analysis • Assess quality outcomes and isolate factors driving quality variations Source: Edifecs
- 9. © QURE 2016 Key Considerations for Cost Management, All Start with Better Care Pre-Admission (surgeon’s office) Better screening and management of conditions prior to admission, to reduce LOS and complications Better patient engagement (and education) pre-admission, to set expectations on pain and other topics and to start discharge planning with a presumption on home discharge when possible During Acute Care (hospital and physicians) Better management of all costs related to implantable vendor choice Better coordination between anesthesia and surgeon (reduction of unwarranted variation, better pain management) Better engagement of physician in managing post acute (what they can do before or at time of discharge, what they can do post discharge) 9
- 10. © QURE 2016 Implementation The Clock Is Ticking…Hospitals Have < 2 Years to Align their Providers Before Penalties Begin 10 Apr. 1: First Performance Period Begins 2015 2016 2017 2018 2019 2020 2021 2022 Design Year 2: • 5% stop loss limit • Target Price: 2/3 hospital, 1/3 regional Year 4 & 5: • 20% stop loss limit • Target Price: 100% regional Year 3: • 10% stop loss limit • Target Price: 1/3 hospital, 2/3 regional Year 1: No payment responsibility Nov 16: Final Rule Posted – Hospital Controls Jul 9: proposed framework in Federal Registrar July 9 - Sep 8: Comment Period – Proposal for Physician Control of Bundle Sources: Centers for Medicare and Medicaid Services
- 11. © QURE 2016 The Paradox for Hospitals You Control the Bundled Payment but Docs Control the Spending • Clinicians lost control of the funds flow but they still have the most control over clinical care • Hospitals are responsible for episode costs that are decided by clinicians – Inappropriate, non standardized care, and/or complications drive up costs • Hospital leadership is limited in the ways they can engage clinicians on changing clinical practice Hospital-Clinician Alignment will be Critical to Success 11 Clinical Independence Financial Risk Source: QURE Healthcare
- 12. © QURE 2016 Home HealthAnchor Hospitalization Physician Fee Schedules SNF LTCH - IRF Readmissions CJR Episode Bundle, MS-DRG 469, 470 Outpatient PT Episode EndsEpisode Trigger 90 Days You Are Now the Payer… …and Consumers Will Choose 1. Costs are going (way) up for patients 2. Consumerism is here Choosing based on cost instead of quality? 3. Quality is its own reward Voluntary Patient Reported Outcomes (PROs) can result in an additional 10% contribution to your composite quality metric score Quality and care standardization reduce your costs PROs!! Sources: Centers for Medicare and Medicaid Services , Edifecs 5
- 13. © QURE 2016 Key Recommendations To Successfully Engage Providers in the CJR 13 Align Around Efficient Practices Develop standardized care pathways that incorporate evidence-based guidance and local physician expertise Target Unnecessary Variation Identify target areas to focus group-level care that will have a significant impact on cost AND quality Gauge and Engage Providers Use tools that facilitate physician engagement, cost and quality measurement Arm Leadership with Resources and Data on Value Closely align with physician leaders to ensure Value = Quality ÷ Cost 2 4 3 1 Increase Value while Reducing CostsSource: QURE Healthcare
- 14. © QURE 2016 Lower Extremity Joint Replacement, Several Expert Consensus Clinical Guides Are Needed 14 Source: respective organization websites
- 15. © QURE 2016 4.3 4.3 4.3 6.5 45.7 0 10 20 30 40 50 Infetion and inflammatory reaction due to other internal orthopedic device, internal fixation device Other mechanical complication of prosthetic Joint Dislocation of prosthetic joint Osteoarthrosis, localized second knee Infection and inflammatry reaction due to internal joint prosthesis Why We Need to Get Care Right: Infections and Prosthetic Complications Drive Surgical Revisions 15 < 3 months 3-6 months 6-12 months >1 year Total Number 151 32 30 9 Percentage 68% 14% 14% 4% American Joint Replacement Registry: Time between Primary Hip and Knee Procedures Performed in 2012-2013 (n=222) 7.3 8.5 14.6 31.7 37.8 0 10 20 30 40 50 Mechanical loosening of prosthetic joint Other mechanical complication of prosthetic joint implant Dislocation of prosthetic joint Peri-prosthetic fracture around prosthetic joint Infection and inflammatry reaction due to internal joint prosthesis Top 5 TKA Revision ICD-9’s (%) Top 5 THA Revision ICD-9’s (%) Sources: American Joint Replacement Registry. The American Joint Replacement Registry Annual Report 2011.
- 16. © QURE 2016 Alignment Means Adoption of Evidence-Based Care to Drive Quality and Value Standardized Care Protocols: Outline most appropriate clinical path for patient types Care path begins with pre-op planning and evaluation through the procedure to the post-hospital stay Post-operative costs are determined by preoperative evaluation and hospital stay 16 CJR represents an opportunity to introduce and emphasize Evidence-Based Care Source: QURE Healthcare
- 17. © QURE 2016 Why We Need to Get Care Right: Initial Care has a Cascading Effect 17 • History • Cardiac Assessment • Physical Assessment • Radiological Exams • Treatment Referral SNF LTCH - IRF Outpatient PT Home Health $$$ $$ $ Re-admissions Patient Reported Outcomes • Anesthesia Selection Pre-Operative Operation PACU/Recovery Post-Operative • Procedure Selection • Implant Selection • Prophylactic Care • Wound Management • VTE • Physical Therapy • Early Mobility • NutritionSource: QURE Healthcare
- 18. © QURE 2016 Watch Recorded webinar Demonstrating Who you Are in CJR Questions? Contact us Courtney.tory@edifecs.com 425-434-2200 Join US Upcoming Webinars Download Presentation in Full
- 19. © QURE 2016 Too Much Variation: The Need to Standardize the History and Physical Examination 19 • Patient history includes onset and duration of symptoms, location and severity of pain, activity limitations (e.g., walking distance, use of assistive devices, and difficulty with stairs) • Physical examination includes gait, knee range of motion, presence or absence of deformity of the knee, stability of the knee, neurologic status (sensory and motor function), vascular status (peripheral pulses), skin, height, and weight Review of 224 TKR patients in 3 affiliated hospitals • Present illness documented in 54% of patients • Pain evaluation documented in 60% of patients • All components of the physical examination documented in 5% of patients • Identifies medical problems that need to be corrected prior to the procedure • Pre-operative activity level and symptoms helps determine the severity of knee arthritis and baseline functionality • Necessary to plan for the surgical procedure 2003 Consensus Guidance Real-Life Practice Clinical Importance Sources: American Joint Replacement Registry, Annual Report 2015 ; American Association of Hip and Knee Surgeons, Total Knee Replacement, Performance Measure Set, Jan. 2013SooHoo N, Tang E, Krenek L, et al. Variations in the quality of care delivered to patients undergoing total knee replacement at 3 affiliated hospitals. Orthopedics 34(5):356, 2011.; American Academy of Orthopaedic Surgeons. AAOS treatment guideline of osteoarthritis of the knee full guideline. 2008. 2013
Editor's Notes
- #11: In response to several commenters requesting a more gradual transition to downside risk and a lower stop-loss limit to allow hospitals more time to gain experience under the CJR model, CMS is finalizing a policy for no repayment responsibility in performance year 1, a stop-loss limit of 5 percent in performance year 2, a stop-loss limit of 10 percent in performance year 3, and a stop-loss limit of 20 percent in performance years 4 and 5 for participating hospitals other than rural hospitals, Medicare-dependent hospitals, rural referral centers, and sole community hospitals. A parallel approach has been finalized for the stop-gain limits to provide proportionately similar protections to CMS and hospital participants, as well as to protect the health of beneficiaries. We are also gradually phasing in repayment responsibility with a reduced discount percentage for repayment responsibility in years 2 and 3.
- #16: Available at: http://orthodoc.aaos.org/ajrr/AJRR%20Annual%20Report%202011-%20FINAL.pdf.
- #19: Here’s a list of challenges for OR, I haven’t made it transaction specific. Challenges: Complexity of the Operating Rules Understanding and implementing all the requirements of the Operating Rules - Connectivity, Supporting multiple modes – Batch/ Real time, Validation, Monitoring , Generating Acks and Responses in line with the Data content and response time requirements, CARC/RARC thrice a year updates. Applicability of the Operating Rules What type of an entity should implement Operating Rules Phase I-III? Prioritizing Getting executive buy in. Coordinating and prioritizing this project with the resource constraints present in the organization– time, staff and budget. Communicating and testing with the provider/ trading partner Trying to adopt such widespread changes without communicating with the provider/ trading partners in reasonable time frames. Also, not providing enough testing window to quality check the implementation with trading partner. Phasing out legacy systems Updating the systems by implementing current versions of the transactions and phasing out old ones – adopting 999 instead of 997; 5010 vs 4010, including the current errata Scalability Identifying a solution that can process millions of eligibility, claim status and remittance advices