maximizing success in a bundled payment environment · maximizing success in a bundled payment...
TRANSCRIPT
Melinda S. Hancock, FHFMA,CPA Partner, DHG Healthcare 2015-16 Chair, HFMA
January 2016
Wisconsin
Maximizing Success in a Bundled Payment Environment
Go Beyond Current Experiences
2
Go Beyond the Status Quo
3
“It isn’t the mountains ahead to climb that wear you out; it’s the pebble
in your shoe.”
Muhammad Ali
CMS Accelerates the Tipping Point for Everyone
4
0
10
20
30
40
50
60
70
80
90
100
2011 2015 2016 2018
Traditional, Fee for Service Alternative Payment Models
“…HHS goal of 30 percent traditional FFS Medicare
payment through alternative payment models by the
end of 2016… 50 percent by the end of 2018”
HHS Press Office 1-26-15 • 85% of payment tied to
quality and value metrics
(ex. HVBB, HRR)
How Are We Doing?
5
Summary of Innovation Models
Accountable Care Episode Based Payment
Initiatives Primary Care Transformation Medicaid & CHIP Population
To Accelerate Testing of New
Models Speed Adoption of Best Practices
ACOs BPCI Models 1-4 Advanced Primary Care Initiatives Reduce Avoidable Hospitalizations for NF residents State Innovation Models :Round 1 & 2 Beneficiary Engagement Model
Advanced Payment ACO ACE Demonstration Comprehensive Primary Care
Initiative
Financial Alignment Incentive for Medicare &
Medicaid Frontier Community Health Integration Community Based Care Transitions
Comprehensive ESRD Care Initiative Oncology Care Model FQHC Advanced Primary Care
Practice Strong Start for Mothers & Newborns Maryland All Payer
Health Care Action and Learning
Network
ACO Investment Model Specialty Practitioner Payment
Model Graduate Nurse Education Medicaid Innovation Accelerator Program Health Care Innovation Round 1&2 Innovation Advisors Program
Next Generation ACO Model Comprehensive Care for Joint
Replacement (CJR) Independence at Home Medicaid Prevention of Chronic Diseases Health Plan Innovation Initiatives Million Hearts
Pioneer ACO Multi Payer Advanced Primary Care
Practice Medicaid Emergency Psychiatric Demonstration Medicare Care Choices Award Partnership for Patients
Rural Community Hospital
Demonstration Transforming Clinical Practice Medicare IVIG Demonstration
Cardiovascular Disease Risk
Reduction
PACE Home Health Value Based Purchasing
Medicare Adv Value Based Ins Design
Enhanced Medication Therapy
Management
Updated 11.24.15 http://innovation.cms.gov/initiatives/
Shaping the Curve Where are we heading?
BPCI and CCJR
8
X
Bundled Payments for Care Improvement
MODEL 1 MODEL 2 MODEL 3 MODEL 4
MODEL NAME
Retrospective
Acute Care
Hospital Stay
Only
Retrospective Acute
Care Hospital Stay
plus Post-Acute
Care
Retrospective Post-
Acute Care Only
Acute Care Hospital
Stay Only
SCOPE OF
EPISODES Entire Hospital Up to 48 Episodes Up to 48 Episodes Up to 48 Episodes
SERVICES
INCLUDED IN
EPISODES
All Part A
services paid as
part of the
MSDRG
Payment
All non-hospice
Part A and B
services during
the initial
inpatient stay,
post-acute
period and
readmissions
All non-hospice
Part A and B
services during
the post-acute
period and
readmissions
All non-hospice
Part A and
B services
(including the
hospital and
physician) during
initial inpatient
stay and
readmissions
PAYMENT Retrospective Retrospective Retrospective Prospective
BPCI DISCOUNT 0.5%, and
increasing over
time
2-3% 3% 3-3.25%
Note: Model 1 is on a different implementation timeline than Models 2, 3 and 4.
10
The Episodes: BPCI
10
• CMS created 48 Episodes, each with up to 15 individual MS-DRG codes
• DHG categorized Episodes into 9 Service Lines; illustrative purposes only
• Model 2, 3, or 4 applicants may select 1-48 Episodes for testing
DHG Category: Vascular Services
• Episode: Major cardiovascular
procedure
– MS-DRGs 237 & 238
• Episode: Medical peripheral
vascular disorders
– MS-DRGs 299, 300, & 301
• Episode: Other vascular surgery
– MS-DRGs 252, 253, & 254
Spine (5) Cardiac
Services (12) Vascular
Services (3)
Orthopedics (10)
Neurology (2) Oncology /
Hematology (1)
Pulmonology (3)
General Surgery (2)
General Medicine /
Internal Medicine (10) http://innovation.cms.gov/initiatives/
bundled-payments/
Example
How do you ‘WIN’ in BPCI?
11
Optimizing Bundles – Requires New Areas of Understanding
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000
Hospital Physician HHA SNF IRF
≈60% of spending
is outside of hospital PAC Setting vitally important to manage
- Discharge status
- Picking PAC partners Readmission often is over 2x the
“spend” of non-readmitted patient
Ex. Target Price = $24k DRG 470, Spending by Setting
Readmit.
Average Episode $
Initial focus may be in two areas of spending that make the greatest
difference: readmissions and post acute care settings.
All data from this slide on is based on 90-Day Episodes - Trimmed
Spending (Risk Track B) in 2012 Dollars , Episodes with less than 250
count are not included, but are available. Data provided by Dobson DaVanzo
• PAC Setting Costs
• Readmission
Opportunity
Distribution of Medicare Spend
13
Two Types of Gain Sharing
14
Net Payment Reconciliation Amount
• Medicare Spend Reduction
Internal Cost Savings
• Hospital Expense Reduction
BPCI Participants by Geography
Changes From Previous Analytic File Phase II Episodes
Phase II Unique BPCI Participants
(BPCI IDs)
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
STAC PGP SNF LTAC IRF HHA
July Analytic File October Analytic File
0
200
400
600
800
1,000
1,200
STAC PGP SNF LTAC IRF HHA
July Analytic File October Analytic File Note: Some PGPs and SNFs originally applied under separate BPCI IDs with different conveners. May
be reason for decrease in IDs in some instances. Also, there should not be any added participants
from July to October due to the fact that October was only for current phase II participants to add or
drop episodes. The 10 added IDs could be omissions/errors from the July file that were corrected in
October.
Type
July
Analytic
File Dropped Added
Total
Change
October
Analytic
File
STAC 1,925 (134) 791 657 2,582
PGP 1,995 (459) 646 187 2,182
SNF 5,874 (1,011) 3,975 2,964 8,838
LTAC 1 0 6 6 7
IRF 17 0 0 0 17
HHA 373 0 144 144 517
TOTAL 10,185 (1,604) 5,562 3,958 14,143
Type
July
Analytic
File Dropped Added
Total
Change
October
Analytic
File
STAC 413 (13) 0 (13) 400
PGP 440 (150) 1 (149) 291
SNF 1,065 (365) 9 (356) 709
LTAC 1 0 0 0 1
IRF 9 0 0 0 9
HHA 102 (1) 0 (1) 101
TOTAL 2,030 (529) 10 (519) 1,511
BPCI Initiative Statistics (As of October)
0
100
200
300
400
500
600
700
800
STAC SNF PGP LTAC IRF HHA
Participants
Model 2 Model 3 Model 4
Type
Unique
IDs Episodes
Unique
IDs Episodes
Unique
IDs Episodes
Unique
IDs Episodes
STAC 391 2,542 9 40 400 2,582
SNF 709 8,838 709 8,838
PGP 240 2,046 51 136 291 2,182
LTAC 1 7 1 7
IRF 9 17 9 17
HHA 101 517 101 517
Total 631 4,588 871 9,515 9 40 1,511 14,143
MODEL 2 MODEL 3 MODEL 4 TOTAL
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
STAC SNF PGP LTAC IRF HHA
Episodes
Model 2 Model 3 Model 4
Phase II Episodes by Geography
* Some PGPs have
applied via their
corporate address
Phase II Episodes by Group
0 100 200 300 400 500 600 700 800 900 1000
Major joint replacement of the lower extremity
Simple pneumonia and respiratory infections
Congestive heart failure
Chronic obstructive pulmonary disease, bronchitis, asthma
Hip & femur procedures except major joint
Sepsis
Urinary tract infection
Acute myocardial infarction
Medical non-infectious orthopedic
Other respiratory
Cellulitis
Stroke
Fractures of the femur and hip or pelvis
Renal failure
Esophagitis, gastroenteritis and other digestive disorders
Cardiac arrhythmia
Gastrointestinal hemorrhage
Nutritional and metabolic disorders
Lower extremity and humerus procedure except hip, foot, femur
Gastrointestinal obstruction
Diabetes
Revision of the hip or knee
Syncope & collapse
Major bowel procedure
Transient ischemia
Medical peripheral vascular disorders
Episode Frequency
Model 2 Model 3 Model 4
Phase II Episodes & Participants by Convener
Type
Unique
IDs Episodes
Unique
IDs Episodes
Unique
IDs Episodes
Unique
IDs Episodes
TOTAL 631 4,588 871 9,515 9 40 1,511 14,143
Remedy BPCI Partners, LLC 142 1,602 486 5,243 628 6,845
Genesis Care Innovations LLC 32 1,217 32 1,217
Liberty Health Partners LLC 59 911 49 130 108 1,041
NaviHealth, Inc. 63 738 63 738
Avamere Health Services 31 615 31 615
Optum 17 595 17 595
Access Innovations LLC 13 347 13 347
No Convener 46 126 26 158 8 39 80 323
HCA Management Services, LP 14 259 14 259
Post Acute Care Network, LLC 10 210 10 210
Premier, Inc. 66 162 66 162
Che Trinity Incorporated 15 149 15 149
Medsolutions, Inc. 8 140 8 140
National Healthcare Corporation 15 135 15 135
Signature Medical Group, Inc. 58 126 58 126
Steward Integrated Care Network, Inc., Geisinger Clinic 8 95 8 95
Advanced Home Care 12 87 12 87
Golden Living (Ggnsc Administrative Services, LLC) 5 86 5 86
Mary Washington Health Alliance, LLC 2 86 2 86
Sante Operations, LLC 7 84 7 84
Ensign Service, Inc. 19 55 19 55
Plum Healthcare Group, LLC 24 54 24 54
MODEL 2 MODEL 3 MODEL 4 TOTAL
Conveners with > 50 Phase II
Episodes
Phase II Episodes by Period of Performance Begin Date
10/1/2013 1/1/2014 4/1/2014 7/1/2014 10/1/2014 1/1/2015 4/1/2015 7/1/2015 10/1/2015
Model 2 48 249 3 2 21 213 995 1336 1721
Model 3 21 647 6 21 622 3693 4505
Model 4 1 34 1 3 1
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Model 2 Model 3 Model 4
Performance Begin Date
important for Model 2 &
3 Precedence
Phase II Episodes by Episode Length
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
STAC PGP SNF LTAC IRF HHA
Post Acute Episode Length Selections
30 Day 60 Day 90 Day
Model 3 Model 2
Model
2 & 3
BPCI Activity: Wisconsin
BPCI Activity: Wisconsin MODEL 2 MODEL 3 TOTAL
Type Unique IDs Episodes Unique IDs Episodes Unique IDs Episodes
STAC 1 1 1 1
PGP
SNF 14 179 14 179
HHA
IRF
Total 1 1 14 179 15 180
0
2
4
6
8
10
12
14
16
STAC PGP SNF HHA IRF
Participants
Model 2 Model 3
0
20
40
60
80
100
120
140
160
180
200
STAC PGP SNF HHA IRF
Episodes
Model 2 Model 3
Wisconsin ranks
15th in the country
in Phase II SNF
episode
participation
BPCI Activity: Wisconsin
0 1 2 3 4 5 6 7 8 9 10
Major joint replacement of the lower extremity
Congestive heart failure
Revision of the hip or knee
Acute myocardial infarction
Simple pneumonia and respiratory infections
Chronic obstructive pulmonary disease, bronchitis, asthma
Fractures of the femur and hip or pelvis
Pacemaker
Lower extremity and humerus procedure except hip, foot, femur
Stroke
Sepsis
Esophagitis, gastroenteritis and other digestive disorders
Coronary artery bypass graft
Medical non-infectious orthopedic
Hip & femur procedures except major joint
Cellulitis
Transient ischemia
Percutaneous coronary intervention
Medical peripheral vascular disorders
Removal of orthopedic devices
Syncope & collapse
Back & neck except spinal fusion
Urinary tract infection
Major cardiovascular procedure
Episode Frequency
Model 2 Model 3
BPCI Activity: Wisconsin
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
STAC PGP SNF HHA IRF
Post Acute Episode Length Selections
30 Day 60 Day 90 Day
Model 2 Model 3
BPCI
Participants
Shaded
Territorie
s
Represen
t CJR
MSAs
BPCI and CJR Activity
Types of Analytics
Data Overload ….
29
Alabama 38
CMS Monthly Claims Data CMS 2009-2012 Claims Data
Baseline
Target
Price
Current
Performance
vs.
Target Price
Trend
Factors
Applied
Questions That Data Helps To Answer
❶ Who else in our market is doing Bundled Payments?
❷ Where are
Beneficiaries/Patients going after leaving our facility?
❸ How can we reduce
utilization of services and prevent bad stuff from
happening during the period of our responsibility?
❹ How can we engage and
integrate other providers to work with us on our bundled
payment?
❺ What does the financial model
look like? Regardless of financial gain/loss, what value do we place on learning and
development?
Model 4 Presence
Trumps Model
2 and 3
Risk Bearing
Performance
Period
Earlier CE-PoP
trumps later CE-
Pop (Not applicable in Model 4)
Models 2 and
3
With Same
Performance
Period Model 2
Trumps
Physician
Group – Model
2 and 3 PGP Initiator
Trumps Non
PGP Initiator
Attending PGP
Initiator
Trumps
Operating
PGP Initiator
❶ Who else in our market is doing Bundled Payments?
Encourages early adoption,
broad implementation, and
partnerships between
various providers
Who Else? Precedence
Precedence Rules
Model 4
Later admission Earlier
admission
Models 2 & 3
Earlier or Same CE-PoP
Model 2
Attending PGP
Operating PGP
Non PGP (Hsp, SNF,IRF, HH,
etc)
Model 3
Attending PGP
Operating PGP
Non PGP (Hsp, SNF,IRF, HH,
etc)
Later CE-PoP
Model 2
Attending PGP
Operating PGP
Non PGP (Hsp, SNF,IRF, HH,
etc)
Model 3
Attending PGP
Operating PGP
Non PGP (Hsp, SNF,IRF, HH,
etc)
Precedence Has a Big Impact
32
Listing of Wisconsin Activity
33
❷ Where are Beneficiaries/Patients going after leaving
our facility?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q12013
Q2 Q3 Q4 Q12014
Hospital Discharge, First Destination
Expired IRF/LTCH SNF HHA Self Care
First Discharge
Setting (MS-DRG
470)
Sample
Hospital Av
Episode
Cost
Home (Self Care) $18,135
Home Health
Agency
$17,505
Skilled Nursing
Fac.
$32,189
Inpatient Rehab
Fac.
$35,037
Encourages use of lowest-
acute post-discharge
setting; IRF and SNF are
hardest hit
Care Pathways illustrates the specific pathway of care of each
episode and its effect on overall episodic spending and ultimately
estimated profit/loss.
Care Pathways
Understanding that their may
be PAC services downstream
of the first PAC setting, the
post acute summary creates
a picture of average spend
per admit by type of setting
and specific provider. SNF,
HHA, IRF, and LTACH
providers are organized by
type and compared to the
average spend of their type
and how many total dollars
are being spent at each
facility for complete episodes.
Post Acute Summary
❸ How can we reduce utilization of services and prevent bad
stuff from happening during the period of our responsibility?
Percent of Episodes
that achieved target
price†
(≤97% of historical
price)
Percent of Episodes
that missed target
price†
(>97% of historical
price)
Met,
Missed
Home 95% 150/158
5% 8/158
Home Health 93% 95/102
7% 7/102
SNF 41% 47/116
59% 69/116
IP Rehab /
LTACH 13%
8/61
87% 53/61
Total 69% 300/437
31% 137/437
Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provider
The Operating Physician Summary provides analysis of episodic
spending by Operating Physician found on the Anchor Hospital record.
This report also contains key metrics on each physician, illustrating how
readmissions affect their episodes and how often these readmissions
may occur after the patient leaves the anchor stay associated with
specific physicians. This is also available by Attending Physician.
Operating Physician Summary
Physician Discharge Trends (available for both Attending and Operating
Physicians) looks at the discharge destination trend of each physician and the
effect of that PAC setting on total episode spending and estimated profitability.
Physician Discharge Trends
❸ How can we reduce utilization of services and prevent bad
stuff from happening during the period of our responsibility?
With Negative Event: (Percent of Episodes that
achieved target price)
Without Negative Event (Percent of Episodes that
achieved target price)
Readmissions 10% 3/30
73% 297/407
ER Visits 35% 23/65
74% 277/372
Preventable
Complications 42% 80/192
90% 220/245
Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provider
Readmission
Summary allows
you to monitor
the readmission
% by month and
understand how
these
readmissions
may affect
overall episodic
spending and
estimated
profit/loss.
Readmission Summary
Readmission Detail is a detailed listing of
every readmission in the current data file.
The graphs summarize these
readmissions by acute care facility,
allowing the user to analyze how many
readmission dollars are being spent at
each facility, both in total and per
readmission. The listing gives key
information relating to the readmission
such as episode, readmitting DRG,
payment amount, and day of episode in
which the readmission occurred.
Readmission Detail
• Total Gainsharing not to
exceed 20% of Historical
Episode Spending
• Physician Gainsharing
capped at 50% of Part B
Professional fees
• Frequently use upside-only
gainsharing contracts with
partners
• Identifying Preferred Providers
Episode
Count
Avg.
Episode
Payment
% of
Episodes
with
Readmit.
% of
Episodes
with ER
Visit
SNF A 53 $34,406 15.1% 1.9%
SNF B 43 $27,969 6.3% 1.3%
SNF C 24 $30,232 8.3% 4.2%
SNF D 20 $37,388 25.0% 15.0%
❹ How can we engage physicians with our bundled payment?
and integrate other providers to work with us?
Encourages consolidation around
high-quality post-acute providers;
can still give Beneficiary choice Source: DHG Healthcare analysis of Medicare claims data 2009-2012 for a sample Model 2 provider
❺ What does the financial model look like? Regardless of financial
gain/loss, what value do we place on learning and development?
“Expenses” “Revenues”
• Financial Model • Low-Risk Learning Opportunity
Why CJR?
45
$12.299 Billion Total Episode Spending
$343 Million Savings to Medicare
2.8% Overall CJR Savings to Medicare
$11 $23 $30 $52 $55
($58) ($101)
($172) ($182)
-$11
$35
$71
$120 $127
-$200
-$150
-$100
-$50
$0
$50
$100
$150
2016 2017 2018 2019 2020
Mill
ions
Medicare’s 5-year CJR Financial Est.
Losses Collected by Medicare from Hospitals
Medicare Gains Distributed to Hospitals
Net Medicare Impact
Major Policies in CJR that did not change
Hospitals are singularly responsible for CJR risk.
IPPS hospitals in CJR selected MSAs are mandated to participate. Non CJR hospitals may not opt-in.
No downside in first performance year.
Applies only to Medicare FFS beneficiaries.
Bundle includes IP stay plus 90-days post-discharge.
Bundles are retrospective, not prospective.
BPCI still “trumps” CJR for risk delegation.
Hospitals may share gains and/or losses with CJR collaborators.
Target prices are re-based every other year.
46
Summary of major CJR changes
❶ CJR start delayed to 4/1/16; truncated first
year
❷ Moving forward with 67 MSAs; 8 MSAs
removed
❸ Quality performance calculations changed
dramatically
❹ Hip fractures
assigned a unique target price
❺ Stop-loss &
stop-gain limits narrowed
❻ More clarification on requirements when
sharing gains/losses with collaborators
❼ CMS actuaries expect greater
savings in final rule ($343M vs. $250M)
❽ Availability of data to
hospitals will be expanded
47
Phasing-in of Regional Pricing
48
Moving forward with 67 MSAs; 8 MSAs removed
Removed MSA
Mandated MSA
• 789 impacted CJR regional hospitals in 67 MSAs
• 67 of 789 (8%) CJR hospitals are already in BPCI for LEJR
• IPPS hospitals in the selected MSAs are required to participate in CJR.
• Census Region still determinant of regional pricing.
• Only exceptions are: • BPCI Phase 2
LEJR hospitals
• Non-IPPS hospitals
• Maryland hospitals
67 selected MSAs by average episode payments
Zoom-in on 2016 performance year
1st / 2nd gainsharing
distribution from CMS
in 2Q 2017.
Download the full 5-year timeline document from www.dhgllp.com/bundledpayments.
Only 2
months of
VPRO
reporting
Performance Year 1 looks like 9 months, but will only include
approximately 6 months of cases. An episode must be initiated
after 4/1/16, and the episode, including 90-day post-discharge
period, must conclude on or before 12/31/16.
Baseline has already been
established.
Complications still
being measured for
PY1 through
3/31/16.
HCAHPS still being measured for PY1 through
6/30/16.
1st / 2nd
reconciliation
report in March
2017 / 2018.
51
Quality measures changed dramatically
52
1. Plot performance percentile for
Complications. Example performance:
65th %ile
2. Plot performance percentile for
HCAHPS. Example performance: 25th
%ile
3. If improved 3 deciles from previous
year on either measure, add
improvement points. Example
performance: complications improved
from 32nd to 65th %ile
4. If voluntary data submitted, add
voluntary data submission points.
Example performance: yes, submitted
data
5. Sum the points.
THA/TKA
Complications
HCAHPS
Survey
≥ 90th 10.00 8.00
≥ 80th and < 90th 9.25 7.40
≥ 70th and < 80th 8.50 6.80
≥ 60th and < 70th 7.75 6.20
≥ 50th and < 60th 7.00 5.60
≥ 40th and < 50th 6.25 5.00
≥ 30th and < 40th 5.50 4.40
< 30th 0.00 0.00
3 Decile Improve.? 1.00 0.80
THA/TKA Voluntary PRO and
limited risk variable data
Yes 2.00
No 0.00
❶
❹
❸ ❷
7.75 + 0.00 + 1.00 + 2.00 = 10.75
❶+❷+❸+❹ =
Quality measures changed dramatically
53
Composite Quality
Score
Quality
Category
Reconciliation
Eligible?
Quality
Incentive
Eligible?
Gains (All
Years)
Losses
(Year 1)
Losses
(Year 2-3)
Losses
(Year 4-5)
< 4.00 Below
Acceptable No No N/A N/A 2.0% 3.0%
≥ 4.00 and < 6.00 Acceptable Yes No 3.0% N/A 2.0% 3.0%
≥ 6.00 and ≤
13.20 Good Yes Yes 2.0% N/A 1.0% 2.0%
>13.20 Excellent Yes Yes 1.5% N/A 0.5% 1.5%
Effective Discount Percentage
Impact of 1% reduction in target price is ≈$25,000
per year for a hospital performing 100 CJR
procedures per year.
Tools for Today: Quality Measures
Quality Measure Your Score Percentile
Quality
Performance
Points
Quality
Improvement
Points
Quality
Composite
Score
Quality
Category
Eligible for
Reconciliation
Payment
Eligible for
Quality
Incentive
Payment
Effective
Discount
Percentage for
Reconciliation
Payment
Hospital-level RSCR following elective
primary THA and/or TKA (NQF #1550)2.4 93 10.00 0.00 10.00
HCAHPS Survey measure 3.44 60 6.20 0.00 6.20
THA/TKA voluntary PRO and limited risk
variable data submissionNO 0.00 0.00
TOTAL 16.20
Yes 1.50%Excellent Yes
54
Hip fractures assigned a unique target price
55
• Partial hip replacements are still part of CJR, but will be given its own target prices by MS-DRG
• Hospital will have four concurrent target prices:
– MS-DRG 470 w/o fracture
– MS-DRG 470 w/ fracture
– MS-DRG 469 w/o fracture
– MS-DRG 469 w/ fracture
• Hip fracture is identified by ICD-9-CM code as the principal diagnosis on the anchor hospitalization claim
MS-DRG 470
without hip
fracture
MS-DRG 470
with hip
fracture
Adjusted Spend per
Episode $24,431 $41,361
% of total MS-DRG
470 episodes 88% 12%
90-day
Readmission Rate 9.1% 27.5%
Hospital ALOS 3.1 days 6.0 days
% discharged to
SNF 35.8% 84.6%
% discharged to
Home Health 59.1% 7.8%
Statistics from Sample Hospital, 2011-2013
Big Data: Hip fracture policy change is significant
Primary
Procedure
% of 2011-2013
Episodes
Average
Episode
Payment
Total knee 58.3% $23,275
Total hip 29.9% $24,280
Partial hip 11.1% $39,272
Total ankle 0.4% $20,166
Admission Type % of 2011-2013
Episodes
Average
Episode
Payment
Elective 83.1% $23,427
Emergency 9.9% $39,168
Urgent 6.3% $28,414
Trauma 0.3% $38,685
Other 0.4% $25,252
Hip fractures commonly:
• Result in partial hip replacement procedures.
• Are emergent or trauma admissions.
These tend to be much more expensive episodes of care.
Source: DHG Healthcare and Dobson | DaVanzo &
Associates research using CMS Public Use Files 11-13 56
Clarified gain/loss sharing requirements
57
• Provided a lot more clarity and
specificity on PGP gainsharing
– PGPs must have distribution
arrangement with members
– Gainsharing funds must not be placed
in PGPs general funds
• Hospital must include quality measures
in collaborator selection and distribution
method
• CJR Collaborators must be listed on the
hospital’s website, updated quarterly
• Gainsharing arrangements must be
entered into before care is furnished to
CJR beneficiaries
SNF HHA
LTCH IRF
Physician Group
Practices Physicians
Non-physician
practitioners
Outpatient therapy
providers
Data availability expanded significantly
58
• Data will be made available “no
less frequently than on a quarterly
basis with the goal of making
these data available as frequently
as on a monthly basis if
practicable.”
• Hospitals must request data one
time, not recurring.
• Beneficiaries may not opt-out of
sharing their data with the CJR
hospital.
• Alcohol and drug abuse patient
records will not be shared. Medic
are
CJR
Data
Hospital Claims-Level
Hospital Summary
Census Region Aggregate
Tools for Today: Provider Intelligence
First PACEpisode
Count
% of Ep. w/
Readm.ALOS
First PAC
Spend
Total Episode
SpendQuality Staffing
Nursing
Staff
Health
Insp.Overall
Total SNF 288 12.6% 19.8 $9,375 $31,600
ALPHA SKILLED NURSING-123456 174 12.2% 16.0 $7,819 $31,197 5 4 4 3 5
CITY SKILLED NURSING-124567 42 15.0% 21.1 $10,100 $33,355 3 4 3 5 2
GOLDEN SKILLED NUR-125678 17 7.1% 16.5 $7,622 $28,221 3 4 4 1 2
ALL OTHER (18) 55 14.0% 29.0 $14,461 $36,788
STAR Ratings
Identify the same information for Home Health (HHA), Inpatient Rehab
(IRF), and Long-Term Acute Care Hospitals (LTACH)
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Big Data: A patient’s care path after discharge matters a lot
Pathway % of
Episodes
Episodic
Spending
Estimated
Target Price
Per Case
Profit/(Loss)
Acute – HHA 28% $19,341 $25,000 $5,659
Acute – SNF 19% $27,752 $25,000 ($2,752)
Acute – SNF – HHA 14% $31,879 $25,000 ($6,879)
Acute – HHA – Readmit. 13% $38,696 $25,000 ($13,696)
Acute – Readmit. 10% $26,626 $25,000 ($1,626)
Acute – SNF – SNF – HHA 6% $50,005 $25,000 ($25,005)
Acute – SNF – HHA – Readmit. 5% $48,506 $25,000 ($23,506)
Acute – HHA – Readmit. – HHA 5% $36,545 $25,000 ($11,545)
Source: DHG Healthcare and Dobson | DaVanzo &
Associates research using CMS Public Use Files 11-13 60
CCJR: SNF Scorecard
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LEJR Episodes are Not Normally Distributed
Bundle Busters
Typical Episode
≈$25,000
Strategies for Now
Develop gainsharing protocols for orthopedic surgeons
Assess opportunity for internal cost savings (ICS)
Focus heavily on post-acute
Enhance episodic care management
Prepare for ongoing data analysis
throughout CJR implementation
Identify quality performance and
prepare for voluntary PRO
reporting
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