episodes of care tenncare episodes. 2016… 2015 2014 2013 2012 …2011 today future value-driven,...
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Episodes of Care
TennCare Episodes
2016…
2015
2014
2013
2012
…2011
Today
Future Value-driven, Coordinated Care
Volume-driven, Fragmented Care
Payment System Changes Fee-for-Service Episode or Comprehensive
Care Payment
Delivery System Changes
Care Coordination
Provider Feedback & Accountability
Measurement around Quality & Efficiency
Market and Regulatory Environment:
Clinical Integration2
CMS Community Care Transition Program
CMS Bundled Payment Pilot
Hospital-Acquired Conditions PenaltiesHITECH/ Meaningful Use PenaltiesTennCare BundlesOptional Commercial BundlesIndividual coverage Requirement
Insurance Exchanges open
DRG Readmissions Penalties
HITECH/Meaningful Use Incentives
Value-Based Purchasing Incentives
Disproportionate Care reductions
Fragmentedevent driven care
Current Episodes of Care Mandated
TimelinesIdentified
Evaluating Other episodes
*CMS indicating Mandated Bundles in the next 2-3 years
Medicare payments tied to quality or value
Year
85% 2016
90% 2018
Medicare move towards Alternate Payment Models (ACO and Bundles)
Year
30% 2016
50% 2018
In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value
Source: May 14th https://aharesourcecenter.wordpress.com/tag/how-many-acos-are-there/
HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as the hospital Value Based Purchasing and the Hospital Readmissions Reduction
Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.
Episode of Care
Who’s accountable: Physician OR OrganizationAccountable For: Quality Outcomes and Cost against Target priceWhat’s at Risk: Revenue; Public Reputation; VolumeHow: Traditional FFS with reconciliation process
Inpatient ProfessionalProfessional Services
Facility & Other Services
3-day pre-admission
Readmission End of Episode: 30-89d, or > 90d
Index Hospitalization Post-Acute: Rehab, Home
Outpatient Professional
Episode anchor: Admission at awardee hospital for included clinical condition – reason for admissions
What does an Episode of Care Payment Model look like? How does it create shared risk?
Mandated Populations- TennCare Populations in wave 1
Episode Trigger(s) Quarterback Start Time Quality Metrics
Acute Asthma Exacerbation
An emergency dept, observation room, or inpt visit for an acute exacerbation of asthma (unless modifier exclusion code)
Facility of trigger claim (by Tax ID) when no transfer or transfer within facility.
Second Facility when transfer between facilities.
Day of Acute Exacerbation Follow up with physician- 43%
Patient on appropriate medication- 82%
End Time
30 days after discharge
Perinatal Live birth diagnosis code or delivery procedure code in any claim type and care setting (unless modifier exclusion code)
Provider or Provider Group (by Tax I.D.) that performs the delivery.
Start Time HIV screening rate- 85%
Group B strep screening rate- 85%
C-section rate- 41%
40 weeks prior to day of admission for delivery
End Time
60 days after discharge
Total Joint Replacement
Surgical procedure for total hip or knee replacement (unless modifier exclusion code)
Orthopedic Surgeon (by Tax ID) performing the total joint replacement
Start Time Readmission rate shifting to reporting only metric45 days prior to
admissionEnd Time
90 days after discharge date
TennCare Episodes of Care “Reconciliation”
1: Setup 2: Analyzing and Initiating
3: Developing Interventions
4: Testing Interventions
5: Hardwiring Successes
6: Monitoring & Sustaining
Exec Sign off
Exec Sign off
TennCare Medicare CommercialInternal Margin/
quality enhancement
Clinical Redesign efforts
Wave 1 Asthma X Phase 5Total Joint X NOSA X Phase 4Perinatal X Cigna On hold
Wave2Colonoscopy X DeferredCholecystectomy X DeferredPercutaneous Coronary Intervention X Deferred
COPD X DeferredInternally Identified
Pneumonia X Phase 4Spine ? XValve Surgery X Phase 6
Population selection and Clinical redesign efforts
Tenn Care- Episodes of Care Baseline PeriodsWave 3- 2015 (performance start 1/2017) Wave 6- 2016 Wave 9-2018
Kidney infection Bronchiolitis & RSV pneumonia Bariatric surgeryGI hemorrhage Hepatitis C Other major bowel (multiple)
Simple pneumonia HIV Female reproductive cancerURI Neonatal Part I (multiple) Lung cancer (multiple)
Upper GI endoscopy Neonatal Part II (multiple) Major DepressionUTI Cellulitis & bacterial skin infection Mild/Moderate Depression
Wave 4- 2015 Wave 7- 2017 Wave 10- 2018Cardiac valve Knee arthroscopy Drug dependence
CABG Hip/Pelvic fracture GERD acute exacerbationODD Lumbar laminectomy Pancreatitis
CHF acute exacerbation Spinal fusion exc. cervical Hepatobiliary & pancreatic cancerADHD (multiple) Diabetes acute exacerbation Renal failure
Wave 5- 2016 Schizophrenia (multiple) Fluid electrolyte imbalanceBreast biopsy Medical non-infectious orthopedic GI obstruction
PTSD Wave 8-2017 Rheumatoid arthritisAnxiety Pacemaker/Defibrillator Wave 11- 2019Otitis Sickle cell Dermatitis/Urticaria
Tonsillectomy Cardiac arrhythmia Kidney & urinary tract stonesBreast cancer (multiple) Hernia procedures Other respiratory infection
Coronary artery disease & angina Epileptic seizureColon cancer Hypotension/Syncope
Anal procedures Bipolar (multiple)Hemophilia & other coag. disorders Conduct disorder
How will we know our performance?
What is the timeline?
Analyst
Director
Project Manager(s)
Project Coordinator
QualityFinance
PCC Centered Resources
Systems Engineering
Ad hoc services- i.e. HITS
Analyst QualityFinance
Admin Lead PCC Physician Lead
Physician Content Experts
Operational Leaders
How will we support this work?Office of Episodes of Care aligned
with PCC roles