CJR – What Does it Mean to Me?
Brian Hickman, CPA, Partner Camille Lockhart, CPA, Partner [email protected] [email protected]
30% by the end of 2016
HHS goal of transitioning from FFS Medicare payments to Advanced
Payment Models (APMs)
50% by the end of 2018
0
10
20
30
40
50
60
70
80
90
100
2011 2015 2016 2018
FFS APMs
Accountable Care BPCI Primary Care
Transition Medicaid and
CHIP Acceleration
Models
Speed Adoption of Best
Practices
ACOs Model 1 Advanced Primary Care Initiative
Reduce Avoidable Hospitalizations
State Innovation Models
Beneficiary Engagement Model
Advanced Payment ACOs Model 2
Comprehensive Primary Care
Initiative
Financial Alignment
Incentive for Medicare and
Medicaid
Frontier Community Health
Integration
Community Based Care Transitions
ACO Investment Model Model 3
FQHC Advanced Primary Care
Practice
Strong Start for Mothers and Newborns
Health Care Innovation Rounds
Health Care Action and Learning
Network
Next Generation ACO Model 4 Graduate Nurse
Education
Medicaid Prevention of
Chronic Diseases
Health Plan Innovation Initiative
Innovative Advisors Program
Pioneer ACO Transforming Clinical Practice
Medicaid Emergency Psychiatric
Demonstration
Million Hearts CJR
The changing health care market: CMMI Innovation Models
DEFENSE: Strategy for Protecting Your Margins
Increase efficiency in
providing care
Improve outcomes
TRIPLE AIM
Improve the patient
experience
Bundled Payments vs. Fee-For-Service AN EPISODIC VIEW
Episode noun. 1. a course of treatment related to a single
illness or condition.
Fee-for-service adjective. 1. separate payments are made to
each provider based on services provided during the episode.
Bundled payment adjective 1. a single payment is made or
payments are adjusted based on a single amount during the
episode or group of episodes.
Comprehensive Care for Joint Replacement Payment Model (CJR) 42 CFR Part 510 [CMS-5516-P]
• 60-day public commenting period on proposal ended Sept 8th
• Numerous comments • Effective April 1, 2016 • Key Changes
2% to 3% discount New targets for fractures 67 MSAs 3 month delay Stop loss reduced Quality measures
MSA Selection 67 MSAs
Missouri Hospitals Located in Select CJR MSAs
BARNES-JEWISH WEST COUNTY HOSPITALBATES COUNTY MEMORIAL HOSPITALBELTON REGIONAL MEDICAL CENTERBOONE HOSPITAL CENTERCAMERON REGIONAL MEDICAL CENTERCENTERPOINT MEDICAL CENTERCHRISTIAN HOSPITAL NORTHEAST-NORTHWESTDES PERES HOSPITALLEE'S SUMMIT MEDICAL CENTERLIBERTY HOSPITALMERCY HOSPITAL JEFFERSONMERCY HOSPITAL ST. LOUISMERCY HOSPITAL WASHINGTONNORTH KANSAS CITY HOSPITALRESEARCH MEDICAL CENTERSAINT FRANCIS MEDICAL CENTERSAINT LUKE'S EAST LEE'S SUMMIT HOSPITAL
SAINT LUKE'S HOSPITAL OF KANSAS CITYSAINT LUKE'S NORTHLAND HOSPITALSOUTHEASTHEALTHSSM HEALTH DEPAUL HEALTH CENTERSSM HEALTH SAINT LOUIS UNIVERSITY HOSPITALSSM HEALTH ST. CLARE HEALTH CENTERSSM HEALTH ST. JOSEPH HEALTH CENTERSSM HEALTH ST. JOSEPH HOSPITAL WESTSSM HEALTH ST. MARY'S HEALTH CENTERST. ALEXIUS HOSPITALST. ANTHONY'S MEDICAL CENTERST. JOSEPH MEDICAL CENTERST. LUKE'S HOSPITALST. MARY'S MEDICAL CENTERTRUMAN MEDICAL CENTER LAKEWOODTRUMAN MEDICAL CENTER-HOSPITAL HILLUNIVERSITY OF MISSOURI HEALTH CARE
Episode Definition - General
Episodes are triggered by hospitalizations of eligible Medicare FFS beneficiaries discharged with diagnoses:
MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complications or comorbidities
MS-DRG 470: Major joint replacement or reattachment of lower extremity without major complications or comorbidities
Episodes include: Hospitalization and 90 days post-discharge All Part A and Part B services, with the exception of certain excluded services that are clinically unrelated to the episode
Episode Definition – Services
Included • Physician services • IP hospitalization (including
readmissions) • IP Psych Facility • LTCH • IRF • SNF • Home Health • Hospital OP services • Independent OP therapy • Clinical lab • DME • Part B drugs • Hospice
Excluded • Acute clinical conditions not arising
from existing episode-related chronic clinical conditions or complications of the LEJR surgery
• Chronic conditions that are generally not affected by the LEJR procedure or post-surgical care
Payment and Pricing – Risk Structure
• Retrospective, two-sided risk model with hospitals bearing financial responsibility • Providers and suppliers continue to be paid via Medicare
FFS • In Year 2, actual episode spending will be compared to
episode target prices • If in aggregate target prices are greater than spending, hospital
may receive reconciliation payment • If in aggregate target prices are less than spending, hospitals
would be responsible for making a payment to Medicare • Opportunities for Hospitals to share both Risk and Gain with
CJR Collaborators
Payment and Pricing – Target Price • CMS intends to establish target prices for each
participant hospital prior to start of each performance period
• Includes 3% discount to serve as Medicare’s savings • Based on blend of hospital-specific and regional
episode data, transitioning to regional pricing. • Essentially competing against yourself in the
beginning
2/3 hospital 1/3 regional
Year 1 & 2 1/3 hospital
2/3 regional
Year 3 100%
regional
Year 4 & 5
Program Waivers
Skilled Nursing Facility CJR would waive the SNF 3-day rule for coverage of a
SNF stay following the anchor hospitalization beginning in Year 2
Patients must be transferred to SNFs rated 3-stars or higher
Beneficiaries must not be discharged prematurely to SNFs
Differences in the use of post-acute care (PAC)...services stood out as key drivers of variation in Medicare spending. If there were no variation in PAC spending, variation in total Medicare spending would fall by 73%
Variation in Health Care Spending: Target Decision Making, Not Geography;
Institute of Medicine; 2013
“
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What Metrics Are Hospitals Looking At?
What makes a difference?
Public data
Staffing & services
Willingness to collect & share data
Patient Experience
What do I Focus On? Public Data – 5-Star Ratings
Quality Measures
Short-stay moderate to severe pain
Short-stay new or worsened
pressure ulcers Long-stay falls
with injury
Overall star rating
Reported vs. adjusted RN and clinical staffing
Survey deficiencies
Build Your Data • Need information to allow you to analyze cost,
payments, length of stay, outcomes, discharge site, type of discharge, etc. for each: • Diagnosis code/illness • Physician • Referring provider • Comorbidity or chronic illness
• Readmission rates • Return to community rates
Working for the Weekend – Am I Built for Transitional Care?
Acute Care Transfers Send to a different hospital so the referral
source won’t find out Implement RTA protocols as early warning
indicators
Admissions Approach
Waiting for the phone to ring Friday-Monday?
Clinical capabilities – nursing, rehab & pharmacy
M-F Day Shift Friday-Monday?
Patient Experience: What do “transitional care” patients want?
Avoid uncertainty in transition, care plan, expectations
Private rooms “My” nurse
Choice (dining, waking, sleeping,
bathing)
Segregation from patients with behavioral
issues/dementia Quick recovery
QUESTIONS?
Brian Hickman, CPA, Partner Camille Lockhart, CPA, Partner [email protected] [email protected]