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 © 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions. 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 © 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions. 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% © 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 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 © 2015 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions. 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: © 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 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 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 • • • • • • • • • • • • 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.