Episodes of Care
TennCare Episodes
Market and Regulatory Environment:
Future
Delivery System
Changes
 Care
Coordination
 Provider
Feedback &
Accountability
Value-driven,
Coordinated Care
Hospital-Acquired Conditions Penalties
HITECH/ Meaningful Use Penalties
TennCare Bundles
Optional Commercial Bundles
Insurance Exchanges open
Individual coverage Requirement
Disproportionate Care
reductions
CMS Bundled Payment Pilot
 Measurement
around Quality
& Efficiency
DRG Readmissions Penalties
Value-Based Purchasing Incentives
HITECH/Meaningful Use Incentives
CMS Community Care Transition Program
Today
 Fragmented
event driven care
Volume-driven,
Fragmented Care
 Fee-for-Service
Payment System Changes
 Episode or Comprehensive
2
Care Payment
 Clinical Integration
Current Episodes of Care
Mandated
Timelines
Identified
Evaluating
Other
episodes
*CMS indicating Mandated Bundles in the next 2-3 years
In historic announcement, HHS sets clear goals and timeline for
shifting Medicare reimbursements from volume to value
Medicare move towards Alternate
Payment Models (ACO and Bundles)
Year
30%
2016
50%
2018
Medicare payments tied to quality
or value
Year
85%
2016
90%
2018
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.
Source: May 14th https://aharesourcecenter.wordpress.com/tag/how-many-acos-are-there/
What does an Episode of Care Payment Model look like?
How does it create shared risk?
Episode of Care
Professional Services
Inpatient Professional
Outpatient Professional
Facility & Other Services
Index Hospitalization
Post-Acute: Rehab, Home
3-day preadmission
Episode anchor: Admission
at awardee hospital for
included clinical condition
– reason for admissions
Who’s accountable:
Accountable For:
What’s at Risk:
How:
Readmission
End of Episode:
30-89d, or > 90d
Physician OR Organization
Quality Outcomes and Cost against Target price
Revenue; Public Reputation; Volume
Traditional FFS with reconciliation process
Mandated PopulationsTennCare Populations in wave 1
Episode
Trigger(s)
Quarterback
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)
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.
when no transfer or transfer within
facility.
Second Facility when transfer
between facilities.
Start Time
Quality Metrics
Day of Acute Exacerbation Follow up with
physician- 43%
End Time
Patient on appropriate
30 days after discharge medication- 82%
Start Time
40 weeks prior to day
of admission for
delivery
End Time
HIV screening rate- 85%
Group B strep screening
rate- 85%
C-section rate- 41%
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
45 days prior to
admission
End Time
90 days after discharge
date
Readmission rate
shifting to reporting only
metric
TennCare Episodes of Care “Reconciliation”
Population selection and Clinical redesign efforts
1: Setup
2: Analyzing
and Initiating
Exec
Sign
off
3: Developing
Interventions
TennCare
Exec
Sign
off
4: Testing
Interventions
Medicare Commercial
5: Hardwiring
Successes
6: Monitoring
& Sustaining
Internal Margin/
quality
enhancement
Clinical Redesign
efforts
X
Phase 5
Phase 4
On hold
Wave 1
Asthma
Total Joint
Perinatal
X
X
X
Colonoscopy
Cholecystectomy
Percutaneous Coronary
Intervention
COPD
X
X
Deferred
Deferred
X
Deferred
X
Deferred
NOSA
Cigna
Wave2
Internally Identified
Pneumonia
Spine
Valve Surgery
?
X
X
X
Phase 4
Phase 6
Tenn Care- Episodes of Care Baseline Periods
Wave 3- 2015 (performance start 1/2017)
Kidney infection
GI hemorrhage
Simple pneumonia
URI
Upper GI endoscopy
UTI
Wave 4- 2015
Cardiac valve
CABG
ODD
CHF acute exacerbation
ADHD (multiple)
Wave 5- 2016
Breast biopsy
PTSD
Anxiety
Otitis
Tonsillectomy
Breast cancer (multiple)
Wave 6- 2016
Wave 9-2018
Bronchiolitis & RSV pneumonia
Bariatric surgery
Hepatitis C
Other major bowel (multiple)
HIV
Female reproductive cancer
Neonatal Part I (multiple)
Lung cancer (multiple)
Neonatal Part II (multiple)
Major Depression
Cellulitis & bacterial skin infection
Mild/Moderate Depression
Wave 7- 2017
Wave 10- 2018
Knee arthroscopy
Drug dependence
Hip/Pelvic fracture
GERD acute exacerbation
Lumbar laminectomy
Pancreatitis
Spinal fusion exc. cervical
Hepatobiliary & pancreatic cancer
Diabetes acute exacerbation
Renal failure
Schizophrenia (multiple)
Fluid electrolyte imbalance
Medical non-infectious orthopedic
GI obstruction
Wave 8-2017
Rheumatoid arthritis
Pacemaker/Defibrillator
Wave 11- 2019
Sickle cell
Dermatitis/Urticaria
Cardiac arrhythmia
Kidney & urinary tract stones
Hernia procedures
Other respiratory infection
Coronary artery disease & angina
Epileptic seizure
Colon cancer
Hypotension/Syncope
Anal procedures
Bipolar (multiple)
Hemophilia & other coag. disorders
Conduct disorder
How will we know our performance?
What is the timeline?
How will we support this work?
Office of Episodes of Care aligned
Director
with PCC roles
Project
Project
Manager(s)
Coordinator
Finance
Analyst
Quality
Ad hoc servicesi.e. HITS
PCC Centered Resources
Admin Lead
Finance
PCC Physician
Lead
Analyst
Physician Content
Experts
Quality
Operational
Leaders
Systems
Engineering