Ready or Not, CMS says GO! LHIMA Annual Meeting April 21, 2016 Denice D. Stelly, RHIA LTC Consulting 1
Comprehensive Care Joint Replacement (CCJR) Hospitals to Manage Episodes of Care for Knee and Hip Joint Replacements 2
2014 services to Medicare fee‐ for service beneficiaries* 400,000+ hip/knee replacements Cost: >$7 billion for hospitalization alone Quality and cost vary greatly among providers and geographic areas *Part A and Part B beneficiaries 3
Comprehensive Care for Joint Replacement Model (CCJR) November 16, 2015- CMS finalized CCJR April 1, 2016 - start date Duration 5-year test ending December 31, 2020 67 geographic areas Louisiana: Monroe, New Orleans/Metarie 4
How is CCJR Different? • M andatory • Hospital-based • Shared savings directly to the hospital performance 5
Financial Impact Under the model, hospitals will be held accountable for all financial risk surrounding the surgery, inpatient stay and care following discharge. “Bundled payment model” • Hospitals will receive additional payments if quality and spending performance are strong…. • IF NOT… hospitals potentially to repay Medicare for portion of spending for care. 6
Goal of the CJR Model Coordinate Care • Physicians • Outpatient Hospital • Home Health Agencies • Skilled Nursing facilities • LTAC • Ambulance Services • Laboratory • Part B Drugs • DME • Hospice 7
Goal of the CCJR Model Improve Patient Care “This model is about improving patient care. Patients want high quality, coordinated care -- not just for a day, but for an entire episode of care. Hospitals, physicians, and other providers who work together can be successful and improve care for patients in this model, and CMS will help providers succeed,” said Patrick Conway, M.D., CMS’ principal deputy administrator and chief medical officer. 8
Goal of the CCJR Model Monetary savings CMS anticipates saving $343 million over the five‐year course of the program 9
Hospital Selection Areas of the country with high volume joint replacement and high historic spending for those patients. BBCPI participation ‐ hospitals that are not already participating in the bundling demonstration. 10
Bundled Payments for Care Improvement (BPCI) Developed by the Center for Medicare and Medicaid Innovation (Innovation Center). Innovation Center created by the Affordable Care Act to test innovative payment and service delivery mode 11
BBCPI Participants in LA Health Care Facility Location Notes * Cardiovascular Care 64030 La Hwy 434, Number of Episodes: 11 // Convening Group - La Heart Lacombe, LA Organization(s):Medsolutions, Inc. Hospital Bone & Joint Clinic 2600 Belle Chase Number of Episodes: 1 // Convening Hwy, Terrytown, LA Organization(s):Remedy BPCI Partners, LLC Southern Orthopaedic 2731 Napoleon Number of Episodes: 1 // Convening Specialists Ave, New Orleans, Organization(s):Remedy BPCI Partners, LLC LA Hospital Medicine 17000 Medical Number of Episodes: 28 // Convening Associates LLC Center Dr, Baton Organization(s):Remedy BPCI Partners, LLC Rouge, LA Our Lady Of The Lake 5000 Hennessy Number of Episodes: 1 // Convening Regional Medical Blvd., Baton Organization(s):Association Of American Center Rouge, LA Medical Colleges 12
Penalty Schedule First year of the program - April 1, 2016 to December 31, 2016l and will not result in any penalties or gains for hospitals. Performance Year Two - Starting Jan. 1, 2017 hospital providers will be “at-risk” for the costs and outcomes for these episodes of care. What will that mean? 13
3‐Day Rule Exemption Starting Jan. 1, 2017 , CMS will waive the skilled nursing facility three-day rule. Participant hospitals may only discharge a CJR beneficiary to a SNF with an overall CMS Five-Star rating of three stars or better at the time of hospital discharge. *Based upon Five-Star methodology, 20% of SNFs in every state will not be included at any given time. 14
Services Included/Bundled A CCJR episode will start on the day a traditional Medicare beneficiary is admitted for hip or knee replacement surgery (MS-DRGs 469 and 470 ) Will continue for 90 days following the beneficiary’s discharge from the hospital The episode includes all Part A and Part B services furnished to the beneficiary during this period with the exception of a specific list of services CMS has deemed clinically unrelated to these episodes. 15
How CCJR works Patients characterized into bundles based MS‐DRG (MS‐DRG 469 and 470.) Hospital at which the procedure was conducted becomes responsible for all care CCJR are 90+ days bundle. 16
How CCJR Works Retrospective Reconciliation Model Annual reconciliation based on CMS Target Pricing 17
Target Price Calcuation Historic baseline - First 2 years - data from 2012-2014 Year 3 and 4 - data from 2014-2016 Year 5 - data from 2016-2018 Regional Blend – hospital’s individual performance and census region’s historical averages. Discount Factor – Under CCJR, CMS has proposed to ease into the discount factor. . 18
Safety Net CMS did mitigate some of the possible losses hospitals could incur through the program with “stop loss” and“stop gain”. 19
Captain of the Ship The hospital and post acute care providers will continue to submit, and CMS will continue to pay, claims for services furnished during a covered episode of care. Annually CMS will compare the actual total cost of care for all episodes provided at a hospital to that hospital’s predetermined episode target price. Hospitals to aggressively manage the entire episode of care hospitals to aggressively manage the entire episode of care. 20
Hospitals to shift their thinking ● Case managers need to shift their thinking to prepare for the future of reimbursement by developing close working relationships with post- acute providers, knowing the services and quality delivered by post-acute providers, and being aware of the costs for the entire episode of care. ● Case managers will not be able to handle all the responsibilities necessary in a bundled payment arrangement if they have large caseloads. 21
Partnership Hospitals will need partners to help them navigate bundled payments and optimize care utilization and efficiency post hospital discharge. CMS estimates savings of $100‐200 million for the Medicare program through CCJR. 22
How to Position for Success • Establish baseline knowledge of program • Identify the opportunities • Position for success by making a link between your services and hospitals for success 23
Skilled Nursing Facilities 3+ Star Ratings Reduce LOS Readmission rates 24
Collect the Right Data Are you in a CCJR market? CMMI Website http://innovation.cms.gov/initatives/ccjr/ If so, what are the big Lower Extremity Joint Replacement (LEJR) hospitals? Top hospitals by volume of LEJR Hospitals’ LEJR as a percentage of all patients Use free resources like CMS Hospital Compare website, American Hospital Directory free hospitals profiles. What do their LEJR episodes look like? Access episodic data resource to assess downstream patterns Look at the big picture – what will matter most to hospital execs? Tie in the way PAC provider performance impacts those key metrics 25
Change is Good! “The changing delivery and payment models mean better communication and coordination between providers and that is where health IT comes into play. LTPAC settings haven’t been as focused on how their systems integrate seamlessly with hospitals, but will increasingly need to.” Michelle Dougherty, MBA, RHIA Sr. Health Informatics Research Scientist RTI International, Center for the Advancement of Health IT 26
Resources The CJR model final rule can be viewed at https://www.federalregister.gov starting November 16, 2015. The waiver notice jointly issued by CMS and OIG is available at https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Fraud-and-Abuse- Waivers.html. For more information on CCJR visit: https://innovation.cms.gov/initiatives/cjr BBCPI Model: https://innovation.cms.gov/initiatives/bundled-payments/ Denice Stelly, RHIA LTC Consulting (337) 298-7103 denicestelly@yahoo.com 27
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