Get Ready for the Comprehensive Joint Replacement Program ... · CJR - Comprehensive Care for Joint Replacement • 767 Hospitals • $4 Billion OCM - Oncology Care Model • 196

9/12/2016

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©2016 Foley & Lardner LLP • Attorney Advertising • Prior results do not guarantee a similar outcome • Models used are not clients but may be representative of clients • 321 N. Clark Street, Suite 2800, Chicago, IL 60654 • 312.832.4500

Friday, September 9, 2016

Get Ready for the Comprehensive Joint Replacement Program – The Time is Now

©2016 Foley & Lardner LLP

Presenters

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Frederick Geilfuss II

Partner

Foley & Lardner LLP

[email protected]

Christopher Donovan

Partner

Foley & Lardner LLP

[email protected]

Dave Terry

CEO & Founder

Archway Health

[email protected]

mailto:[email protected]



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General Overview

■ Comprehensive Care for Joint Replacement (“CCJR”) Model

■ Acute care hospitals in certain selected geographic areas will be responsible for the costs of episodes of care for lower extremity joint replacement or reattachment of a lower extremity (and, as proposed, surgical hip/femur fracture)

■ Episode covers all Medicare Part A and Part B payments from hospitalization through 90 days post-discharge

■ Mandatory participation of roughly 800 hospitals in 67 MSAs

■ Program began April 1, 2016

■ Downside risk starts January 1, 2017

■ 5 year program

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Reconciliation Payment Model

■ Retrospective, two-sided risk model with hospitals bearing financial responsibility

− Providers and suppliers continue to be paid via Medicare FFS

− At the end of the performance year, actual episode spending will be compared to the episode target price

− Generally, anchor hospital receives benefit if costs below target or bears risk if costs exceed target

■ If costs below target, reconciliation payments will be phased in and capped (stop-gain):

− Years 1 and 2: Capped at 5%

− Year 3: Capped at 10%

− Years 4-5: Capped at 20%

■ If costs above target, hospital responsibility to repay CMS will be phased in and capped (stop-loss):

− Year 1 (2016): No responsibility to repay Medicare

− Year 2: Capped at 5% of target prices

− Year 3: Capped at 10% of target prices

− Years 4 and 5: Capped at 20% of target prices

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Establishing Target Prices

■ Each participant hospital will have its own episode target prices set by CMS based on 3 years of historical data

■ Target based on a blend of hospital-specific and regional costs: − Years 1 and 2: 2/3 hospital-specific costs and 1/3

regional

− Year 3: 1/3 hospital-specific costs and 2/3 regional

− Years 4 and 5: 100% regional costs

■ 3% discount to serve as Medicare’s savings; quality impact

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Overview

■ Hospital at core

■ Hospital may share upside and downside, but requires a detailed contract with collaborators (providers furnishing services as part of the episode)

■ Contract requirements are detailed

■ Hospital must keep 50% of downside; no one but collaborator can be responsible for more than 25%

■ Physician upside limited to 50% of the total Medicare-approved amounts under the physician fee schedule

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Overview (cont’d.)

■ Program Waivers − Waives requirement for 3-day inpatient stay

before SNF admission (if SNF has 3-star rating)

− For post-discharge home visits, waives incident to direct supervision for physician services Maximum of nine visits during episode

− Telehealth -- waives geographic site requirement

− Preferred providers in discharge planning Easing of requirements?

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Sharing Agreements

■ Hospitals may negotiate agreements for sharing gain and loss that they bear

■ Opportunities lie in aligning other providers for furnishing efficient services

■ Analyze cost of care furnished and by whom in an episode

■ DRG for hospital; opportunity for physician gainsharing

■ Post-acute care services − Reduce hospital readmissions

− More home care

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Requirements for Sharing Agreements

■ Detailed written agreement

■ Hospital must develop a written set of policies for selecting providers/suppliers, which include quality criteria

■ Criteria for sharing must be based on quality, not volume or value

■ For PGPs, PGP must contribute to care redesign and be clinically involved in CJR beneficiaries’ care (e.g., care coordination, design of care)

■ Agreement must tie provider compliance plan to CJR

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CJR: Fraud and Abuse Waivers

Three Fraud and Abuse Waivers:

1. Waiver for Distribution of Gainsharing Payments and Payment for Alignment Payments Under Sharing Arrangement (“Gainsharing and Alignment Payment Waiver”)

2. Waiver for Distribution Payments from a Physician Group Practice to a Practice Collaboration Agent (“PGP to Collaboration Agent Waiver”)

3. Waiver for Patient Engagement Incentives Provided by Participant Hospitals to Medicare Beneficiaries in Episodes (“Patient Engagement Waivers”)

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CJR Program Management

Preparation, Design & Implementation

September 9, 2016

www.archwayhealth.com 10

www.archwayhealth.com

Contents

• About Archway Health

• Bundled Payment Market Update

• CJR Program Management • Phase I: CJR Diagnostics & Opportunity Assessment

• Phase II: Program Design

• Phase III: Implementation

• Getting Started

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About Archway Health

100% Focused on Bundled Payment – it’s all we do

Active in all of the CMS bundled payment programs – BPCI, CJR, OCM, EPM Also developing commercial bundle

Have built a comprehensive, one stop shop bundled payment platform

Working with dozens of customers & hundreds of providers across the country

Real results – all of our partner hospitals & physicians are earning significant savings

The Archway team has been working in these programs since their inception in 2011

Focus To partner with providers &

payors to execute bundle payment programs

Mission To fix healthcare through

payment reform

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Archway’s comprehensive, straightforward approach has helped provider organizations achieve significant savings in their BPCI orthopedic bundles.

$2,000 – $4,700

savings/ bundled patient

• Increased patient

satisfaction

• 85%+ provider

compliance with INACT

process

• Reduced readmissions

• Reduced post-acute

facility costs

• 9-17% reconciliation

savings

$31,000

$26,300

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

Baseline PerformancePrices

Performance PeriodCost

About Archway Health - Results to Date

Archway’s Bundled Payment Performance

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We’ve learned that there are four elements to the most effective bundled payment programs.

Bundled Payment Pyramid

About Archway – Program Design

• Basic requirement

• Creates new incentives

for accountability &

improvement Bundled Payment Contract

• Identify opportunities & risks

• Prioritize areas for

improvement Data Analytics

• Leverage existing protocols &

guidelines

• Case manager engagement

• Driven by nurses & hospitalists

Care

Management

• New & better ways to care for acute & chronic

patients

• Optimal provider, patient, payor alignment

• Driven by hospital – specialist alignment

• Biggest driver of improvement

Inno-

vation

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Bundle Payment Initiatives Participants Estimated Market Size*

BPCI - Bundled Payment for

Care Improvement

• 1,457 providers • $10 Billion

CJR - Comprehensive Care for

Joint Replacement

• 767 Hospitals • $4 Billion

OCM - Oncology Care Model • 196 Oncology Groups

• 17 Health Plans

• $2 Billion

Episode Payment Model - EPM • 1,200 hospitals

• 2 cardiac & 1 new ortho bundle

• $6 Billion

• Starts 7/1/17

BPCI 2.0 • Voluntary

• Focus on physician driven bundles

• Size TBD

• Starts early 2018

Commercial • @ 40 active programs

• Lots of activity in the last 6 months

Total • 3,620 • $25+ Billion

* Estimated based on publicly available information

Bundled Payment Market

Bundled Payment Market Size

Bundle payment is shifting from a niche payment model to an emerging strategic priority.

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Archway CJR Approach

Phase I: Program

Preparation

Phase II: Program Design

Phase III: Program

Implementation

• Pricing analysis by bundle

type

• Opportunity benchmarking

• Detailed Surgeon analysis

• Post-acute provider

analysis

• Quality performance

analysis

• Designate & train CJR

Oversight Team

• Develop work plan & timeline

for focus areas

• Execute surgeon gainsharing

strategy

• Formalize preferred provider

network

• Quality improvement plan

• Identify & track CJR patients

• Implement care management

approach

• Collect & track quality metrics

• Track quality & financial

performance

• Monitor preferred providers

• CMS program compliance

• Ongoing learning &

improvement

Main Objective: Identify

priority areas of focus

Main Objective: Finalize CJR

strategy and operational plan

Main Objective: Improve

quality & reduce costs

CJR Program Preparation, Design & Implementation Process

Archway has developed a comprehensive process for helping hospitals succeed within the CJR program.

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The first step is to episodic spending by type of service - outpatient, home health, SNF, etc.

Demo Data

Archway CJR Approach: Phase I Phase I: Program

Preparation

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Best practice benchmarking is an important step that helps CJR hospitals understand their opportunities and risks within their organization and market.

Opportunity Assessment Controllable Cost Benchmarking

Elective DRG 470


Preparation

Illustrative

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$45,461

$44,008

$29,003

$26,699

$26,133

$25,590

$24,301

$23,767

$23,716

$23,632

$22,897

$22,658

$21,601

$- $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000

(19) D

(17) E

(129) F

(40) G

(37) H

(21) I

(31) J

(90) K

(43) L

(259) M

(121) N

(345) O

(120) P

Anchor Stay SNF HHA Readmits IRF Other

Physician

(volume)

Estimated Elective 470 Price


Preparation

Understanding historical episodic costs by surgeon is essential to developing a CJR strategy and defining short term priorities.

Major Joint Surgeon Cost Performance Profile Elective DRG 470

Illustrative

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Preparation

There is also significant variation in the episodic cost of care by Skilled Nursing provider.

Episodic Cost of Care by Skilled Nursing Facility

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SNF Medicare Compare Ratings


Preparation

It is also important to work with high quality post-acute providers.

Quality Staffing Survey Overall

SNF A ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★

SNF B ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★

SNF C ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★

SNF D ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★

SNF E ★ ★ ★ ★ ★ ★ ★ ★ ★

SNF F ★ ★ ★ ★ ★ ★

SNF G ★ ★ ★ ★

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Illustrative

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CJR pricing is adjusted based on each hospital’s performance within a Composite Quality Score that includes complication rates, HCHAPS scores, and patient reported outcomes (PRO) submission.

Archway CJR Approach: Phase I

CJR Quality Metrics Calculations

Hospital Campus

RSCR Score (4/1/11-3/31/14)

Percentile Rank

Points Assigned

HCAHPS Star Rating (7/1/14-6/30/15)

Percentile Rank of HLMR*

Points Assigned

Patient Reported Outcome Reporting

Composite Quality Score

Effective Discount Percentage for Year 1

Brookline 2.4 94 10 3 57 5.6 2.0 17.6 1.5%

Cole Valley 3.2 48 6.25 4 64 6.2 0.0 12.5 2.0% *HCAHPS Linear Mean Roll-up score (HLMR) was derived from publicly available Hospital Compare data using CJR final rule formula.

Phase I: Program

Preparation

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Illustrative


Archway CJR Approach: Phase II

Phase I: Program

Preparation


Phase III: Program

Implementation


type




analysis


analysis


Oversight Team


for focus areas


strategy


network




approach



performance




improvement









Phase II:

Program Design

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• One team is better than many

• Designate an empowered Project Leader with “Oomph”

• The Care Management Team can make a huge difference

• Physician gainsharing helps too

• Keep it simple

• “Crawl, walk, run”

• Track program performance frequently

• Care management

• Financial

• Build continuum partnerships, but don’t get locked in

• “Trust but verify”

• Switch when necessary

• Joint Class leaders

• Care Management leader

• Discharge planning

• Surgeon champion

• Finance

• C-Suite representation

Recommended Team Principles

Key Team Members

Phase II:

Program Design Archway CJR Approach: Phase II

CJR Focused Team

Designating a single, focused and manageable CJR implementation team is key to effective program design and success.

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Gainsharing Rules & Principles

Gainsharing is important tool for aligning incentives and improving performance.

• Strive to keep the structure simple &

objective

• Focus on high volume, high influence

providers

• Use gainsharing to align incentives &

drive performance

• Gainsharing with SNFs creates unique

risk protection within CJR

• Physician gainsharers limited to 50% of

Part B collections in CJR

• CJR Hospitals should only distribute

gains if there are net gains for the

overall program

Gainsharing Agreements

Phase II:

Program Design

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Preferred Provider Network Development

• Daily health status updates

• BPCI participation strongly preferred

• Focus on quality improvement

• Commitment to reduce LOS & Readmits

• Designated CJR point person

• Data sharing

• Continuous learning & improvement

• Regular care management meetings

Preferred Provider

Expectations

We have developed a simple, data-driven process to develop a preferred provider network.

Phase II:

Program Design Archway CJR Approach: Phase II

Facility Episode Volume

LOS Score Episode

Cost Score Overall

Star Rating Collaboration

Total Score

OAK STREET REHABILITATION & NURSING CENTER

140 3.00 4.00 5 5 5

MAIN STREET REHABILITATION & NURSING CENTER

112 1.00 2.00 5 5 5

MOUNTAIN VIEW REHABILITATION & NURSING CENTER 135 2.00 4.00 3 3 3

FOREST VIEW REHABILITATION & NURSING CENTER

147 1.00 2.00 4 3 3

ELM STREET REHABILITATION & NURSING CENTER

150 5.00 1.00 3 2 3

CITY VIEW REHABILITATION & NURSING CENTER

137 1.00 1.00 4 2 2

LAKE VIEW REHABILITATION & NURSING CENTER

120 1.00 1.00 2 2 1

OCEAN VIEW REHABILITATION & NURSING CENTER

123 1.00 1.00 3 1 1

Sample Skilled Nursing Facility Analysis

90 Day Hospital-Initiated Bundles from 1/1/14-12/31/14

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Detailed CJR Program Workplan

Phase II:

Program Design

At the end of Phase II we generally develop a detailed workplan designed to accomplish the goals outlined in the Design Phase.

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Archway CJR Approach

Phase I: Program

Preparation


Phase III: Program

Implementation


type




analysis


analysis


Oversight Team


for focus areas


strategy


network




approach



performance




improvement









Phase III: Program

Implementation

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CJR Care Model Design INACT Process

Steps Description

1. Identify Identify patients in bundled payment

programs

2. Notify Notify patients they are enrolled in a bundled

payment program

3. Assess Assess patients to determine if they are Low,

Medium or High risk for complications

4. Care Plan Develop a 90 day care plan that maps out key

transition steps across the episode

5. Track Track patient progress as they transition from

hospital to home

Archway has collaborated with participating providers to develop a simple bundled payment care management model that is working well in the market.

Archway CJR Approach: Phase III Phase III: Program

Implementation

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Real Time Patient Tracking

Archway Carelink Dashboard

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Archway Analytics Web-Enabled Dashboard

Costs by DRG & Type

Archway CJR Approach: Phase III

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Archway Analytics Web-Enabled Dashboard

Physician Reporting

Archway CJR Approach: Phase III

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Getting Started

CJR Program Priorities

To get started we recommend initiating the Phase I program preparation analytics.

• Identify your hospital’s current phase – Prep, Design Implementation

• Designate CJR Team • Identify 2-3 initial CJR priorities • Surgeon Gainsharing • Preferred Provider Network Development • Patient Tracking • Performance Tracking

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©2016 Foley & Lardner LLP • Attorney Advertising • Prior results do not guarantee a similar outcome • Models used are not clients but may be representative of clients • 321 N. Clark Street, Suite 2800, Chicago, IL 60654 • 312.832.4500 34

Questions & Answers

Documents

Get Ready for the Comprehensive Joint Replacement Program ... · CJR - Comprehensive Care for Joint Replacement • 767 Hospitals • $4 Billion OCM - Oncology Care Model • 196