Driving Transformation for
Comprehensive Care for Joint Replacement
(CJR)
Understand • Redesign • Align
INSERT CUSTOMER NAME
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
THE RAPID TRANSITION TO
VA L U E - B A S E D C A R E
January 28, 2015
Bundled Payment for Care
Improvement cohorts went live
30% OF
MEDICARE
PAYMENTS
VOLUNTARY
October 2013 to
October 2015
Health Care Transformation
Taskforce (group of nation’s
largest health systems and
insurers) announces 2020
goal of shifting 75% revenue
tied to alternative payment
models
2016
TIED TO ALTERNATIVE
PAYMENT MODELS
(ACOS/BP)
2020
Health Care
Transformation Taskforce
(75% adherence):
CMS setting a trend and
entire market is shifting
2009
Acute Care Episode (ACE)
demonstration to test the use
of a bundled payment for
both hospital and physician
services for a select set of
inpatient episodes of
care for orthopedic and
cardiovascular procedures
January 26, 2015
U.S. Department of Health
and Human Services (HHS)
sets goals and timeline for
Medicare reimbursement shift
from volume to value
MANDATORY
November 16, 2015
CJR Announced:
Final rule posted
2018
July 9, 2015
CJR Announced: Mandatory
Total Joint episode-based
bundled payment model for
DRGs 469 & 470
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
50% OF
MEDICARE
PAYMENTS
TIED TO ALTERNATIVE
PAYMENT MODELS
(ACOS/BP)
C J R O V E RV I E W
The Comprehensive Care for Joint Replacement Model
• Mandatory bundled payment model for Total Joint Replacement and reattachment of the lower extremities
(DRGs 469 & 470)
• Separate Target Pricing for elective and Hip Fracture patient population
• 67 metropolitan statistical areas (MSA) / 800+ hospitals
• Begins April 1, 2016 (5-year duration)
• CMS-defined, required quality metrics
• Target price based on blended hospital and regional spending
• Retrospective annual reconciliation
• Excludes episodes covered under an existing Bundled Payments for Care Improvement contract
Acute Care
Hospital Stay
and Post-Acute
Care 90 Days
Post-Discharge
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F I N A L C J R PA RT I C I PAT I N G M S A S
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
O P T I M I Z I N G T H E O RT H O P E D I C VA L U E C H A I N
The Total Joint episode of care represents a
significant opportunity to improve quality
through reduced variation, resulting in
decreased cost.
IP PAC
SNF
HHA
Average DRG 470 90 Day Episode Cost
READMISSION
TOTAL
COST*
OUTPATIENT
QUALITY
P H YS I C I A N
INPATIENT
Addressing this segment of the episode is
going to be a new focus under CJR and
potentially a challenge for Hospitals to manage
PA S T
FOCUS
CJR
FOCUS
* Cost to Medicare
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
S A M P L E H O S P I TA L C J R O P P O RT U N I T Y
Average DRG 470 Episode Cost
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
FLORIDAA
Hospital
HOSPITAL
FLORIDA B
Hospital
HOSPITAL
ZEPHYRHILLS
Index Admit
HELEN
ELLIS
Hospital
C
MEMORIAL
HOSPITAL
Professional
FLORIDA D
Hospital
HOSPITAL
WATERMAN
OP_DME
FLORIDAE
Hospital
HOSPITAL
CARROLLWOOD
Readmits
HHA
FLORIDAF
Hospital
HOSPITAL
TAMPA
SNF
SOUTH
Region
ATLANTIC
BENCHMARK
Benchmark
Other IP PAC
• Data includes 9 months of 2014 from the CMS Cl aims Files. The graph s hows all claims data for DRG 470 that i s reported under a given CMS ID. Region mappings by s tate are from CMS
(http://i nnova tion.cms.gov/initiatives/ccjr/) and include all facilities in those states except MD. The M|S DCOSP Aggressive Benchmark represents the weighted average episode cost of
a l l the facilities within the best performing quartile with DCOSP that were launched prior to 2012. The M | DCOSP ExpectedBenchmark represents the average episode cost of all the
fa ci lities with DCOSP that were launched prior to 2012. The M|S Aggressive and Moderate DCOSP Benchmarks' Index Admissioncosts are set equal to the National Average Index
Admi ssion cost to normalize for wage index differences. IPPS Inpatient costs exclude IME, DSH and Capital but include Uncompensated care costs which began i n FY 2014. T hose costs
were not isolated i n the 100% cl aims data files for removal, although they will be removed i n the final CJR ca lculations. Facility a nd regional costs reflect actual claims paid a nd a re not
a djusted to remove the impact of wage i ndex, therefore comparisons between facility, region a nd benchmarks reflect differences in wage indices and uncompensated care costs.
• Final target price for CCJR will be based on episodes initiated 1/1/2012-12/31/2014 and will reflect a blend of facility and wage index normalized regional costs
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
THE RISING BAR OF CJR
INCREASING RELIANCE ON REGIONAL PERFORMANCE
YEAR 1
YEAR 2
YEAR 3
Limited upside
potential only
Limited upside
and downside
More upside and
downside risk
Historical HOSPITAL
Performance Weighting
66.6%
66.6%
33.3%
0%
0%
Historical REGIONAL
Performance Weighting
33.3%
33.3%
66.6%
100%
100%
1.5%-3%
1.5%–3%*
1.5%–3%*
1.5%–3%
1.5%–3%
No loss
5% gain cap
5% loss cap
5% gain cap
10% loss cap
10% gain cap
20% loss cap
20% gain cap
20% loss cap
20% gain cap
Risk Model
Range for Discount used
for Reconciliation
Amount; Determined by
Composite Quality Score
Loss/Gain Cap
YEAR 4
YEAR 5
Maximum allowable Maximum allowable
upside and
upside and
downside risk
downside risk
* The discount for repayment amount purposes is 1% lower in years 2 and 3, effectively 0.5% - 2%.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
THE RISING BAR OF CJR
Hospitals will be pressured to improve their baseline episode performance to
outpace the rest of their region
HISTORICAL
H O S P I TA L
PERFORMANCE
YEAR 1
YEAR 2
YEAR 3
YEAR 4
Regional markets will become increasingly
competitive as bundled payment programs,
including BPCI, continue to evolve and
drive target prices down
Those who can’t compete we
expect to see:
• Joint programs marginalized
• Consolidation
• Unprofitability
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
YEAR 5
HISTORICAL
REGIONAL
PERFORMANCE
CJR COMPLIANCE REQUIREMENTS
CMS may add 25% to a repayment amount on a participant hospital's reconciliation report if the participant
hospital fails to timely comply with a corrective action plan or is noncompliant with the model's requirements.
General Program Compliance
•
•
•
•
Hospital compliance plan that includes CJR
Board level oversight of CJR
Written policies for selection of collaborators with established quality criteria
Hospital oversight of compliance with collaborators
Hospital Beneficiary Notification Compliance
• Patient CJR education upon admission
• Patient notification of PAC provider options
Collaborator Beneficiary Notification Requirements
1) CJR Physician:
Required to provide written notice of the structure of the CJR model and the existence of the sharing arrangement
with the hospital at the time the decision for surgery is made
2) CJR PAC Provider/Supplier:
Required to provide written notice of the existence of the CJR sharing arrangement with the hospital at the time the
beneficiary first receives services during the episode
Collaborator Compliance Plan
Collaborators must have their own compliance plan in place related to CJR
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
CJR COMPLIANCE REQUIREMENTS
CMS may add 25% to a repayment amount on a participant hospital's reconciliation
report if the participant hospital fails to timely comply with a corrective action plan or
is noncompliant with the model's requirements.
•
General Program Compliance
•
Hospital Beneficiary Notification Compliance
•
Collaborator Beneficiary Notification Requirements
•
Collaborator Compliance Plan
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S
Episode Data Collection and Analytics
Understand where you are, where
you need to focus and how your
results are emerging
Care Redesign
Implementation
Episode-focused
care redesign that
improves quality
care, reduces
variation and
decreases cost
across the
continuum
Understand
Data
Provider Alignment
Creating the right
formal/informal
agreements to drive
provider alignment
through impactful
engagements that
improve care and
reduce cost under
the bundle
Align
Providers
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
Redesign
Care
P O W E R O F PA RT N E R S H I P
Your CJR success is what we
were built to do:
Performance Intelligence
Understand
Data
to help you understand, benchmark
and make informed decisions
Implementation Programs
to drive care redesign
Alignment Strategies
to align risk-based incentives
Align
Providers
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
Redesign
Care
COMPREHENSIVE EPISODE MANAGEMENT
P R E - H O S P I TA L
I N PAT I E N T
CMS Claims Analysis
Understand
Data
Patient-Reported
Outcomes (PRO)
Hospital-Reported
Outcomes (HRO)
Redesign
Care
Coordinated System of Care
MEDICAL DIRECTORSHIP
GAINSHARING AGREEMENT
CO-MANAGEMENT AGREEMENT
Align
Providers
POST-ACUT E
C L I N I C A L LY I N T E G R AT E D N E T W O R K
Integration Models
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PRO
C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
We have the capability and expertise to...
• Use your internal hospital data to measure historical, current and
ongoing performance within your facility
• Process your external CMS claims data to understand CJR
program, opportunities, risks and impact
• Capture patient reported outcomes (clinical and functional) and
satisfaction to improve quality composite score
• Validate your CMS data for accuracy and discrepancies
• Analyze reconciliation data to inform gainsharing models
Our Performance Intelligence solution is more than data collection,
it’s your action plan for care transformation and provider alignment.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
Internal Data Collection and Analytics
Hospital Reported Outcomes
Dashboards that track and benchmark
hospital performance
• Patient clinical, functional and satisfaction outcomes
• Maximize key opportunities for CMS payments
• Gainsharing metric reviews
• Especially useful when gainsharing on internal cost savings,
normally complicated and contentious calculations
Performance analyst quarterly data reviews
• Review key metrics that impact internal costs and quality
• Build/adjust care redesign program using expert data analysis
CJR requires achievement of certain levels of performance in a composite quality score
in order to receive any annual cost savings
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
External Claims Data
Bundled Payment Analytics
Detailed financial and actuarial analysis on CMS claims data
• Manipulate, review and interpret your data for variation and
opportunity assessment
• Reconcile your CMS claims data to ensure you’re maximizing payment
• Review of CMS provided target price for reasonableness
• Benchmark your performance vs. your history, your region and best practice
CJR dashboard and reporting
•
•
•
•
Volume and episode cost analysis
Post-acute analysis
Readmissions
Preliminary estimated NPRA
Gainsharing structuring and calculations
• Use CMS claims and quality data to help you structure and drive your program
CJR requires achievement of certain levels of performance in a composite quality score in order
to receive any annual cost savings
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
Composite Quality Scoring
Your financial outcomes will be directly impacted by your quality performance
Each quality measure is weighted to impact the overall composite score
Total composite score determines:
1. Eligibility to receive positive Net Payment Reconciliation Amounts (NPRA)
2. Target price discount rate for reconciliation payment and repayment
Quality Measure
Weight Contributed to Composite Score
THA/TKA Complications
50%
HCAHPS
40%
PRO
10%
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C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
Composite Quality Score:
Payment and Repayment
Performance
Year
Composite
Quality Score
Quality Category
Eligible for
Reconciliation
Payment
1
<4.0
Below Acceptable
No
No
3.00%
Not applicable
≥4.0 and <6.0
Acceptable
Yes
No
3.00%
Not applicable
≥6.0 and ≤13.2
Good
Yes
Yes
2.00%
Not applicable
>13.2
Excellent
Yes
Yes
1.50%
Not applicable
<4.0
Below Acceptable
No
No
3.00%
2.00%
≥4.0 and <6.0
Acceptable
Yes
No
3.00%
2.00%
≥6.0 and ≤13.2
Good
Yes
Yes
2.00%
1.00%
>13.2
Excellent
Yes
Yes
1.50%
0.50%
<4.0
Below Acceptable
No
No
3.00%
3.00%
≥4.0 and <6.0
Acceptable
Yes
No
3.00%
3.00%
≥6.0 and ≤13.2
Good
Yes
Yes
2.00%
2.00%
>13.2
Excellent
Yes
Yes
1.50%
1.50%
2-3
4-5
Eligible for
Discount for
Quality Incentive Reconciliation
Payment
Payment
Discount for
Repayment
Amount
Quality hurdle for reconciliation eligibility: participant must have a hospital composite score of 4 or greater to qualify and receive positive NPRA
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
U N D E R S TA N D Y O U R D ATA
Understand
Data
V O L U N TA RY PAT I E N T
R E P O RT E D O U T C O M E S
Final PRO Elements
• The percent of eligible procedures
to be reported ramps up by
performance year from 50% in year
1 to 80% in year 5
Date of birth
Race
Ethnicity
Date of admission
Date of procedure
HIC#
• Reporting of PRO adds to the
overall composite score which
reduces the discount on target
prices
Body mass index
Total painful joint count
Chronic narcotic use
Quantified spinal pain
SILS2 questionnaire
• Timing of collection for post-op data
elements is between 270-365 days
VR-12 OR PROMIS-Global
KOOS
HOOS
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S PS C JR DATA TIM E F RA MES
DEC JAN
FEB
1Q2016
MAR
APR
MAY
2Q2016
JUN
JUL
AUG
3Q2016
Patient Reported Data
Real time data
Internal Hospital Data
Quarterly data reviews focus on data
from 1 quarter (3 months) prior
External CJR Claims Data
Quarterly data reviews focus on data from
3 quarters (10 months) prior
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
SEP
OCT
4Q2016
NOV
DEC
JAN
1Q2017
C J R C R I T I C A L S U C C E S S FA C T O R S :
REDESIGN YOUR CARE
Redesign
Care
We have a dedicated clinical implementation
team committed to…
• Leveraging your episode data to redesign care to drive success
under CJR.
• Building alignment between the hospital, providers and staff.
• Standardizing clinical protocols and care pathways.
• Reducing variation to improve quality and patient satisfaction.
• Care coordination across the entire continuum.
• Streamlining post-acute utilization and optimization.
Care Redesign solutions are everywhere but only an Implementation
Program is going to help reduce variation and drive transformation in
care delivery across your entire Total Joint episode.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
REDESIGN YOUR CARE
Redesign
Care
Redesign Your Total Joint Episode
Destination Centers of Superior Performance®
Redesign care across the Total Joint episode to:
• Deliver care to differentiate your hospital from
those in your region
• Standardize care delivery process/protocols
• Align/engage administration, staff and providers
• Reduce cost drivers and improve quality metrics
and patient satisfaction through outcomes
management
• Focus on post-acute utilization/efficiency to control
episode spend and readmissions
• Maximize CJR composite quality score to ensure
gainsharing goals and success
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
REDESIGN YOUR CARE
Redesign
Care
Comprehensive Episode Management
What We Do:
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C J R C R I T I C A L S U C C E S S FA C T O R S :
ALIGN YOUR PROVIDERS
Align
Providers
We are able to help drive provider
engagement that…
• Fully complies with CJR compliance
regulations
• Fosters collaboration with select,
proven-value providers (surgeons and
post-acute providers)
• Incentivizes providers to change
practice patterns
• Utilizes data and targets to drive fair and
compliant gainsharing
Care Coordination is critical, but designing an Alignment Strategy that
incentivizes provider engagement will drive success under CJR.
NOTE: All gainsharing structures must be independently evaluated by the client and their legal counsel for compliance with legal and regulatory gainsharing requirements.
Stryker Performance Solutions does not provide legal advice.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
ALIGN YOUR PROVIDERS
Align
Providers
C o lla b o ra tor A gre e ments
The content of the collaborator agreement outlined in the final rule resembles items that are
required by CMS for BPCI in the form of an implementation protocol.
Likely elements include:
• Information about planned care redesign and care coordination
• A description of how success will be measured
• Management and staffing information
• Required to ensure that the collaborator is in good standing with Medicare and has a valid
TIN or NPI
• Collaborator must have a CJR compliance program
• Methodology for accruing and calculating internal cost savings
• Describe quality criteria for the collaborator
Note: Collaborator must meet hospital defined quality criteria in order to receive a gainsharing payment.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
C J R C R I T I C A L S U C C E S S FA C T O R S :
ALIGN YOUR PROVIDERS
Align
Providers
We help you design, implement and manage
alignment structures through:
• Strategic selection of provider partners
• Gainsharing structures to maximize
results for patients, providers,
physicians and payors
• Metrics and targets to incentivize
episode-focused quality improvement
and cost reduction
• Internal cost saving calculations using
Hospital Reported Outcomes
NOTE: All gainsharing structures must be independently evaluated by the client and their legal counsel for compliance with legal
and regulatory gainsharing requirements. Stryker Performance Solutions does not provide legal advice in the development of a
gainsharing structure. Data was taken from the Original Reconciliation of Quarter 2 2014. The results are for illustrative purposes
only of what can be achieved. The results are not a guarantee of what will be realized. The physicians shown may have a different
gainsharing arrangement than one being implemented. Physicians A and B met their capped limit.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
P O W E R O F PA RT N E R S H I P
Partnering with SPS empowers you to be
successful in CJR
Your CJR success is what we were built
to do:
Understand
Data
Performance Intelligence
to help you understand, benchmark and
make informed decisions
Implementation Programs
to drive care redesign
Alignment Strategies
to align risk-based incentives
Align
Providers
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
Redesign
Care
P O W E R O F PA R T N E R S H I P :
B U N D L E D PAY M E N T E P I S O D E C O S T R E D U C T I O N
Are you considering a partner who is…
• Taking full downside risk in Bundled Payments for Care Improvement program exclusively for the Total Joint
episode of care
• Proven in Care Redesign solutions that help align providers and hospitals
• Worked on over 30 bundles across 25 organizations, with a focus on Total Joint Bundles
• Providing actionable dashboard information using internal data and also reconciling it with CMS claims data
• Conducting CMS data audits and reporting discrepancy in results and corrections to NPRA reconciliations
worth thousands of dollars
SPS Client Average DRG 470 Episode Cost Baseline vs. 2014
On average, our
BP clients have
reduced their
episode cost by
*
10%
Baseline includes claims data from July 2009 through
June 2012. 2014 includes the full year of claims data.
* In the first performance year
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
P O W E R O F PA RT N E R S H I P
We’ve helped over 250 clients transform and redesign care
1 Year Post Launch
Joint Replacement
Before
Launch
SPS 50th Percentile
Metric
Average
Result
Annual
Impact
Result
Annual
Impact
Result
Annual
Impact
395
435
10%
465
18%
498
26%
$7.4 M
$8.2 M
$800,000
$8.7 M
$1.3 M
$9.4 M
$2.0 M
Length of Stay
3.29
2.95
$73,950
2.67
$144,150
2.47
$204,180
Discharge Home or Home Health*
72%
78%
$642,953
85%
$1,264,768
86%
$1,590,977
Complications
2.4%
1.6%
-0.8%
0.6%
-1.8%
0.5%
-1.9%
Readmissions
2.7%
2.4%
-0.3%
1.7%
-1.0%
1.2%
-1.5%
Blood Transfusion
20%
13%
$26,970
8%
$54,870
4%
$77,688
Patient Satisfaction
N/A
97%
Annual Volume (First Year)
Reimbursement
SPS 75th Percentile
98%
Denotes CJR quality composite score metrics: complications and patient satisfaction
*Annual Impact is achieved by reduced claims for post-acute care (Home Health, SNF, Acute Rehab)
Example provided for illustration purposes only and should not be construed as a guarantee of future results
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
SPS 90th Percentile
100%
P O W E R O F PA RT N E R S H I P
Our database contains over 400K patient records from over 250 clients
Denotes CJR quality metrics: complications, readmissions and patient satisfaction
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
WHY SPS?
• Specialist, not Generalist
• Comprehensive approach with Data Analytics, Care Redesign and Provider Alignment
• Proven Care Redesign solutions, since 2005 (250+ implemented programs nationwide)
• Experience with all CMS Bundled Payment programs
• Experts in risk-based payment programs with proven results
• Our orthopedic registry includes 250+ hospitals with 500,000 patient records and 1,500
surgeons
• We have helped our clients reduce their episode cost by 10% on average
• CMS claims data analytics, reconciliation, and discrepancy reporting
• A dedicated team assigned to you that includes:
• CJR Project Manager
• Data Performance Analyst
• Care Redesign Program Manager (RN/PT)
• Shared Risk agreements plan options
• Experienced implementation team of Orthopedic Surgeons, Administrators, Actuaries,
Financial/Data Analysts, Clinical Managers, Lawyers
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
P O W E R O F PA RT N E R S H I P
This is what you need to do:
Understand Redesign Align
This is what we are built
to do:
Performance Intelligence
to help you understand, benchmark
and make informed decisions
Understand
Data
Implementation Programs
to drive care redesign
Alignment Strategies
to align risk-based incentives
Align
Providers
Redesign
Care
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
Questions?
The Power of Partnership
Y O U R C J R PA R T N E R
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
REGISTER SOON!
W W W. S T R Y K E R P E R F O R M A N C E S O L U T I O N S . C O M
9th Annual Orthopedic and Spine Summit:
Optimizing Patient Care throughout the Continuum.
Physician and Hospital Executive Leadership Course
Preparing for Fundamental Payment Reform
•
•
•
•
•
•
•
•
Reducing Variation within the Joint Replacement Episode to Drive Care
Transformation (Including Outpatient Joint Care)
Developing a Standardized Process for Geriatric Fracture Care
Navigating the Care Pathway for the Spine Patient
Achieving Operational Excellence through Surgical Service Optimization
Using Data to Understand, Build and Maintain Care Pathways
Keeping Physicians & Practice Models Relevant, Profitable and Efficient
•
Improving Quality and Cost through Value Based Contracts
Medicare’s Comprehensive Care for Joint Replacement (CJR)
it in Everyone’s Future?
Engaging Physicians to Drive Patient Centric Change Under CJR and
Bundled Payment for Care Improvement Initiative (BPCI)
• Gainsharing Metric Development Workshop
© 2014 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
Is
CCJR VS. CJR
PROPOSED CJR VS. FINAL CJR
Proposed Comprehensive Care for Joint
Replacement (CJR)
FINAL Comprehensive Care for Joint Replacement (CJR)
Participation Type
Mandatory for all Acute Care Hospitals in 75 MSAs; 90
day post-discharge duration only.
Mandatory for all Acute Care Hospitals in 67 MSAs; 90 day postdischarge duration only.
Quality Metrics
Fixed Metrics (hospital) - Minimum thresholds must be
achieved for Complication Rate, Readmission Rate, &
HCAHPS to receive NPRA.
Fixed Metrics (hospital) – a composite score for Complication Rate,
HCAHPS & PRO that provides financial incentive for performance
and improvement. Hospital chooses quality metric(s) for
collaborator gainsharing.
Basis for Target Price
Blended hospital-specific and regional spending with
increasing emphasis on regional spending, from rolling
3 year baselines. Prospectively developed trend factors.
Blended hospital-specific and regional spending with increasing
emphasis on regional spending, from rolling 3 year baselines.
Prospectively developed trend factors. Now includes risk
stratification for hip fracture.
Target Price Discount
Discount 2% of target price reduced by 0.3% if entity
complies with voluntary reporting
Discount 1.5 to 3% of target price based on achievement with
quality metrics. Discounts for the purpose of deficit calculations
are reduced by 1% in year 2.
Positive & Negative
NPRA Caps &
Exclusions
Same as BPCI. Hospital cannot receive more than 20%
of the target price. Maximum savings achieved by entity
set at 20% of the target price. Physician and nonphysician gainsharing capped at 50% of their fees.
Upside and downside caps scaled by year increasing from 5% in
year 1 (no downside risk in year 1), 10% in years 2-3,and 20% in
years 4-5 of the target price. Physician and non-physician
gainsharing capped at 50% of their fees.
Stop-Loss Limit
Awardee cannot lose more than 20% of dollars at risk
(target price times the number of episodes)
Maximum deficits charged to entity set at 0 for year 1. Scaled by
year increasing from 5% in year 2, 10% in year 3, and 20% in years
4-5 of the target price
Readmissions
Inclusions/Exclusions
Exceptions for specific exclusions around
Trauma/Oncology
Unclear how much it differs from BPCI. Includes hospice services,
which are excluded under BPCI.
Compliance
Very few compliance requirements
Significant complex compliance requirements
This new proposal does not affect the ongoing Bundled Payment for Care Improvement (BPCI) pilot upon which it is modeled. For those organizations currently
enrolled in BPCI, the program will continue to operate under its existing parameters for the full three year contracts unless CMS issues specific rule changes
that indicate otherwise.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
SPS OFFERING
C J R P O RT F O L I O O F F E R I N G
Opportunity
Assessment
Episode
Analytics
Episode
Management
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Episode Cost Analysis
•
•
•
Analysis of 100% claims data, prior to CMS data release
Volume and episode financial impact vs. benchmarks
Readmit rates, post acute variability and outliers
Service Line Assessment
•
•
•
On-site interviews, observation and data analysis vs. benchmarks
Care Continuum Delivery Model gap assessment and best practices
Care redesign readiness, recommendations and priorities
CJR Analytics and Support
•
•
•
•
•
Intake, validation, manipulation and storage of CMS quarterly claims data
Target price verification, reconciliation analysis and estimated NPRA
Gainsharing structure, metrics and calculation support
Dedicated CJR Program Manager to drive care management process
CJR Education and Implementation Toolkit
Joint Replacement Care Redesign
•
•
•
•
Implementation of Marshall Steele Destination Center for Total Joint
Standardized care delivery process and clinical protocols
Post-acute utilization and efficiency to reduce spend and readmissions
Hospital & Patient Reported Outcomes quarterly review process
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.

O P P O RT U N I T Y A S S E S S M E N T
Episode Cost Analysis
•
Analysis of 100% claims data, prior to CMS data release
•
Volume and episode financial impact vs. benchmarks
•
Readmit rates, post acute variability and outliers
Service Line Assessment
•
On-site interviews, observation and data analysis vs. benchmarks
•
Care Continuum Delivery Model gap assessment and best practices
•
Care redesign readiness, recommendations and priorities
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
E P I S O D E A N A LY T I C S
Episode Cost Analysis
•
Analysis of 100% claims data, prior to CMS data release
•
Volume and episode financial impact vs. benchmarks
•
Readmit rates, post acute variability and outliers
Service Line Assessment
•
On-site interviews, observation and data analysis vs. benchmarks
•
Care Continuum Delivery Model gap assessment and best practices
•
Care redesign readiness, recommendations and priorities
CJR Analytics and Support
•
Intake, validation, manipulation and storage of CMS quarterly claims data
•
Target price verification, reconciliation analysis and estimated NPRA
•
Gainsharing structure, metrics and calculation support
•
Dedicated CJR Program Manager to drive care management process
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
E P I S O D E A N A LY T I C S
CJR Education and Implementation Toolkit
•
•
•
•
•
•
•
•
•
•
•
•
Patient notification requirements
Beneficiary protections – review of beneficiary protections under CJR
Gainsharing parameters - clarification of gainsharing requirements,
Collaborator Agreement Guide
Program Waivers
Quality Metrics definition and measurement
Basic CJR Education Materials (suitable for Leadership, Physicians, and Staff)
CJR Exclusion Logic and Rules
How CJR, BPCI and ACOs Work Together
Mock Reconciliation Explanation and Walk-through
Facilitate Hospital Data Request per CMS requirements
Compliance Requirements/Plans for gainsharers and hospitals
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
EPISODE MANAGEMENT
Episode Cost Analysis
•
Analysis of 100% claims data, prior to CMS data release
•
Volume and episode financial impact vs. benchmarks
•
Readmit rates, post acute variability and outliers
Service Line Assessment
•
On-site interviews, observation and data analysis vs. benchmarks
•
Care Continuum Delivery Model gap assessment and best practices
•
Care redesign readiness, recommendations and priorities
CJR Analytics and Support
•
Intake, validation, manipulation and storage of CMS quarterly claims data
•
Target price verification, reconciliation analysis and estimated NPRA
•
Gainsharing structure, metrics and calculation support
•
Dedicated CJR Program Manager to drive care management process
•
CJR Education and Implementation Toolkit
Joint Replacement Care Redesign
• Implementation of Marshall Steele Destination Center for Total Joint
• Standardized care delivery process and clinical protocols
• Post-acute utilization and efficiency to reduce spend and readmissions
• Hospital & Patient Reported Outcomes quarterly review process
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
EPISODE MANAGEMENT
Implementation Tool Kit Delivered with Education
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•
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•
•
•
•
•
•
•
•
•
Patient notification requirements
Beneficiary protections – review of beneficiary protections under CJR
Gainsharing parameters - clarification of gainsharing requirements,
Collaborator Agreement Guide
Program Waivers
Quality Metrics definition and measurement
Basic CJR Education Materials (suitable for Leadership, Physicians, and Staff)
CJR Exclusion Logic and Rules
How CJR, BPCI and ACOs Work Together
Mock Reconciliation Explanation and Walk-through
Facilitate Hospital Data Request per CMS requirements
Compliance Requirements/Plans for gainsharers and hospitals
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
D AT A A N A LY T I C S D E TA I L S
C J R D ATA A N A LY T I C S T I M E L I N E
OCT NOV DEC
2016
JAN
FEB MAR APR MAY
JUN
JUL
AUG SEPT OCT NOV DEC
2017
JAN
FEB MAR APR MAY
JUN
JUL
Episode Cost
Opportunity
Analysis
Detailed Baseline
Financial Analysis
(Including Review
of CMS Provided
Target Price For
Reasonableness)
Ongoing
Quarterly
Reporting and
Analysis
*
Annual
Reconciliation
Analysis
* Pending CMS data delivery timeline and content
© 2014 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
E P I S O D E C O S T O P P O RT U N I T Y A N A LY S I S
The CJR Episode Cost Analysis is a financial and actuarial analysis of the
potential financial opportunity
•
Development of estimated target prices and
potential financial opportunity relative to
benchmarks
•
Analysis of key metrics across facility, system (if
applicable), region and benchmarks:
- Average episode costs by type of service
- 90 day readmission rates
- Assessment of high cost outlier cases
- Volumes
Stryker Performance Solutions will provide the information your
organization needs to understand the opportunities, risks and
potential financial impact of CJR
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
D E TA I L E D B A S E L I N E F I N A N C I A L A N A LY S I S
Detailed analysis of baseline CMS claims data identifies areas for
opportunity and focus
• Volumes and Mix by DRG and hip fracture status in baseline and
trends over time
• Review of CMS provided target prices for reasonableness
• Episode cost trends by year comparing facility, system and region
• Post acute usage trends
- Drivers of cost (type of service, LOS, provider)
- Top providers by type of claim (SNF, HH, IRF)
- Usage and mix by category
• Financial opportunity
- Reflecting most recent actual average episode costs, baseline
target prices and benchmarking comparisons
- Comparison to best practice and national benchmarks
• Readmission trends to drill into types of readmissions, frequency
and leakage
• Outlier impact to determine magnitude of cases above thresholds by
DRG and hip fracture status
Stryker Performance Solutions will provide recommendations
for next steps under CJR based on information shown in the data
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
S P S O N G O I N G Q U A RT E R LY R E P O RT I N G
A N D A N A LY S I S
Our Quarterly Reporting and Analysis monitors emerging results relative to expectations
and provides you with actionable insights.
Episode cost analysis
•
Relative to target prices, baseline and trends over time
•
Cost trends by year comparing facility, region and
national costs
•
Analysis of cost variation by first site of service post discharge
Post acute analysis relative to baseline and trends
•
Cost drivers by service type, LOS and provider
•
Usage rates and mix of services
Readmission analysis relative to baseline and trends
•
Frequency, location and type of readmission
Outlier impact analysis
Volume analysis by DRG and hip fracture status and mix
changes over time
© 2014 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
S P S A N N U A L R E C O N C I L I AT I O N A N A LY S I S
Our Reconciliation Analysis will help review CMS results, identify performance drivers, and
determine gainsharing allocations
Manipulate and interpret your data for variation and opportunities
• Detailed financial and actuarial analysis on CMS claims data that
drills down to the episode level
• Volume, episode cost, readmissions, generated savings, and
physician performance analysis
• Post-acute analysis including provider quality ratings, costs and
utilization
Reconcile your hospital’s internal data with CMS claims to
ensure you’re maximizing payment
• Review CMS provided target price for reasonableness, and
episode and true-up auditing
• Calculation Error Report submission as your CMS liaison
Benchmark your performance vs. your history, your region, and
best practices
• Leverage comparative opportunities and strengths to improve your
own performance.
Gainsharing structuring and calculations
• Use CMS claims and quality data to help structure and drive your
program
50
© 2014 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
S A M P L E B U N D L E D PAY M E N T A N A LY T I C S R E P O R T S
H O S P I TA L Q 2 2 0 1 4 - Q 1 2 0 1 5 AV E R A G E
EPISODE COST AND VOLUME BY PHYSICIAN
Average episode cost by Operating Physician
DRG 470 (w/o hip fractures) 2014
EXAMPLE ONLY
$50,000
58
70
60
50
37
$30,000
33
$20,000
33
32
40
30
35
20
13
Episode Volume
$40,000
$10,000
10
4
$0
0
Physician A
Physician B
Avg - Index Admit
Avg - HHA
Physician C
Physician D
Avg - Professional
Avg - SNF
Physician E
Physician F
Avg - OP_DME
Avg - Other IP PAC
Physician G
Physician H
Avg - Readmit
Episodes - Index Admit
All physicians should look to reduce IP PAC costs when clinically appropriate. Hospitals’ IP PAC costs and utilization for Total Joint Replacements of the Lower
Extremity are unusually high compared to what is seen around the rest of the country.
Average costs are untrimmed for outliers. During actual reconciliations episodes will be trimmed at 2 standard deviations above the regional mean.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
DRG 470 EPISODE COST BY FIRST SITE
O F S E RV I C E ( W / O H I P F R A C T U R E S )
Average Episode Cost by First Site of Service 2014
$50,000
EXAMPLE ONLY
$45,000
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
HOME
HH
Index Admit
OP_DME
SNF
Professional
Readmit
Patients discharged home or with home health have far lower episode costs than SNF and IP PAC discharges.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
OTHER IP PAC
Post Acute
DRG 470 DISTRIBUTION BY FIRST
S I T E O F S E RV I C E ( W / O H I P F R A C T U R E S )
FSS Distribution Q2 2014-Q1 2015
100%
EXAMPLE ONLY
75%
50%
25%
0%
Baseline
2014Q2
HOME
2014Q3
HH
SNF
2014Q4
2015Q1
OTHER IP PAC
Distribution by discharge disposition has not changed much since the baseline although overall post acute care costs per episode have increased dramatically.
Opportunities exist to reduce the use of IP PAC and reevaluate the HHAs and SNFs to which patients are discharged.
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
2 0 1 4 D R G 4 7 0 AV E R A G E S N F
COST BY PROVIDER (W/O HIP FRACTURES)
2014 DRG 470 SNF Providers by Cost per Service
$0
$2,000
SNF A| 3 Stars
3
SNF B| 5 Stars
2
SNF C| 4 Stars
24
SNF D| 2 Stars
6
SNF E| 3 Stars
5
SNF F| 4 Stars
6
SNF G| 3 Stars
2
SNF H| 5 Stars
21
SNF I| 3 Stars
2
SNF J| 2 Stars
2
0
$4,000
$6,000
$8,000
$10,000
•
•
$14,000
$16,000
$18,000
$20,000
EXAMPLE ONLY
5
10
Avg Trended Final Pmt
•
$12,000
15
20
25
Episode count
The majority of episodes discharged to SNFs are going to SNF C and SNF H; however, average costs at SNF C exceed average costs at
SNF H by $7,000
Costs reflect average episode cost for SNF services on episodes that have those services; costs are not trimmed for outliers
Providers listed reflect the top 75% of the total volumes of SNF providers
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.
30
9 0 D AY R E A D M I S S I O N R AT E S — D R G 4 7 0 ( W / O
HIP FRACTURES)
EXAMPLE ONLY
20%
Hospital A
Hospital B
15%
10%
5%
0%
Baseline
•
•
•
2014Q1
2014Q2
2014Q3
2014Q4
In Q4 2014, readmission rates are down from the baseline at both hospitals
Readmits represent 90 day readmits to any facility for DRGs that are considered related for the BPCI family according to CMS methodology; some DRGs
are excluded
Readmit rates and counts reflect patients who are readmitted during an episode of care, not the number of times they are readmitted
© 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.