Episodes of Care TennCare Episodes

Market and Regulatory Environment Changes: Future Value-driven, Coordinated Care Delivery System Changes Care Coordination Provider Feedback & Accountability Measurement around Quality & Efficiency 2016 2015 2014 2013 2012 …2011 2019… 2018 2017 Hospital-Acquired Conditions Penalties HITECH/ Meaningful Use Penalties TennCare Bundles Optional Commercial Bundles CMS Bundled Payment Pilot DRG Readmissions Penalties Value-Based Purchasing Incentives HITECH/Meaningful Use Incentives CMS Community Care Transition Program Fragmented event driven care Volume-driven, Fragmented Care Payment System Changes Fee-for-Service Episode or Comprehensive Care Payment Clinical Integration

Current Episodes of Care in TN Mandated Timelines Identified Evaluating Other episodes

In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value Medicare move towards Alternate Payment Models (ACO and Bundles) Year 30% 2016 50% 2018 Medicare payments tied to quality or value Year 85% 2016 90% 2018 HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as the hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. Source: May 14th https://aharesourcecenter.wordpress.com/tag/how-many-acos-are-there/

What does a Bundle look like? Professional Services Inpatient Professional Outpatient Professional Facility & Other Services Index Encounter Post-Acute: Rehab, Home, etc Pre-admission timeframe Readmissions, etc. End of Episode: Includes a set period of time (i.e. 30- 60 days) Episode anchor: Admission, ED visit, observation day at hospital for included clinical condition Payment Traditional FFS payment to all providers Episode Reconciliation For Medicare: If Medicare payment > target price, awardee must repay If Medicare payment < target price, Medicare will pay difference to awardee For TennCare: If the average cost is higher than acceptable, share the excess cost. If the average cost is lower than commendable, and quality benchmarks met, share cost savings below commendable line. If average cost lower than gain sharing limit, share cost savings but only above gain sharing limit.

Mandated Populations- TennCare Populations in Wave 1 - January 2016 Episode Trigger(s) Quarterback Start Time Quality Metrics Acute Asthma Exacerbation An emergency dept., observation room, or inpt. visit for an acute exacerbation of asthma (unless modifier exclusion code) Facility of trigger claim (by Tax ID) when no transfer or transfer within facility. Second Facility when transfer between facilities. Day of Acute Exacerbation Follow up with physician- 43% Patient on appropriate medication- 82% End Time 30 days after discharge Age: 2 - 64 Perinatal Live birth diagnosis code or delivery procedure code in any claim type and care setting (unless modifier exclusion code) Provider or Provider Group (by Tax I.D.) that performs the delivery. HIV screening rate- 85% Group B strep screening rate- 85% C-section rate- 41% 40 weeks prior to day of admission for delivery Age: 12 - 64 60 days after discharge Total Joint Replacement Surgical procedure for total hip or knee replacement (unless modifier exclusion code) Orthopedic Surgeon (by Tax ID) performing the total joint replacement Readmission rate shifting to reporting only metric 45 days prior to admission Age: <64 90 days after discharge date

Mandated Populations- TennCare Populations in Wave 2 – January 2016 Episode Trigger(s) Quarterback Start Time Quality Metrics COPD ED visit or inpatient admission for acute COPD exacerbation. Facility where the ED visit or inpatient admission occurred. Day of Acute Exacerbation Follow- up care within the post- trigger window. End Time Age: 18 - 64 30 days after discharge Colonoscopy A colonoscopy procedure. Physician who performs the procedure. No quality metrics tied to gain sharing. 30 days prior to procedure 14 days after discharge Cholecystectomy A Cholecystectomy procedure. Hospital admission in the post-trigger window. 90 days prior to procedure Acute PCI A PCI procedure. Facility where procedure is performed. Day of procedure 30 days after procedure Non Acute PCI

Mandated Populations- TennCare Populations in Wave 3 – January 2017 Episode Trigger(s) Quarterback Start Time Quality Metrics Upper GI Endoscopy An EGD procedure. Physician who performs the procedure. 7 days before procedure No quality metric tied to gain sharing. End Time Age: 1 - 64 14 days after procedure Respiratory Infection A diagnosis for respiratory infection. Physician who diagnosed the respiratory infection. Day of diagnosis Age: 90 days of age - 64 14 days after diagnosis Pneumonia A diagnosis for pneumonia. Facility where pneumonia was diagnosed. Follow-up care within the post- trigger window. 30 days after discharge Urinary Tract Infection Outpatient A diagnosis for UTI. outpatient UTI. Admission within the trigger window for ED triggered episodes or non-ED triggered episodes. 14 days after the diagnosis Inpatient Facility where the inpatient UTI was treated. Age: 18 - 64 Gastrointestinal Hemorrhage A diagnosis for GI Hemorrhage. Facility where the GI Hemorrhage was treated.

Mandated Populations- TennCare Populations in Wave 4 – January 2017 Episode Trigger(s) Quarterback Start Time Quality Metrics Attention Deficit and Hyperactivity Disorder (ADHD) A diagnosis for ADHD. Physician with the plurality of visits for ADHD during the episode window. Day of diagnosis Percentage of valid episodes that meet the minimum care requirement. (1) End Time Age: 4 - 20 179 days after diagnosis Bariatric Surgery A bariatric surgery procedure. Physician who performs the procedure. Follow-up care within the post- trigger window. Day of procedure Age: 18 - 64 30 days after discharge Coronary Artery Bypass Graft (CABG) A CABG procedure. Facility where the procedure was performed. Age: <64 Congestive Heart Failure (CHF) Acute Exacerbation A diagnosis for CHF. Facility where the CHF was treated. Oppositional Defiant Disorder A diagnosis for ODD. visits for ODD during the requirement. (2) Age: 4 - 18 Valve Repair and Replacement A heart valve replacement or repair procedure. The minimum care requirement is set at 5 visits/claims during the episode window. These may be a combination of E&M and medication management visits, therapy visits, level I case management visits, or pharmacy claims for treatment of ADHD. The minimum care requirement is set at 6 therapy and/or level I case management visits during the episode window.

Tenn Care- Episodes of Care Baseline Periods Wave 3- 2015 (performance start 1/2017) Wave 6- 2016 Wave 9-2018 Kidney infection Bronchiolitis & RSV pneumonia Bariatric surgery GI hemorrhage Hepatitis C Other major bowel (multiple) Simple pneumonia HIV Female reproductive cancer URI Neonatal Part I (multiple) Lung cancer (multiple) Upper GI endoscopy Neonatal Part II (multiple) Major Depression UTI Cellulitis & bacterial skin infection Mild/Moderate Depression Wave 4- 2015 Wave 7- 2017 Wave 10- 2018 Cardiac valve Knee arthroscopy Drug dependence CABG Hip/Pelvic fracture GERD acute exacerbation ODD Lumbar laminectomy Pancreatitis CHF acute exacerbation Spinal fusion exc. cervical Hepatobiliary & pancreatic cancer ADHD (multiple) Diabetes acute exacerbation Renal failure Wave 5- 2016 Schizophrenia (multiple) Fluid electrolyte imbalance Breast biopsy Medical non-infectious orthopedic GI obstruction PTSD Wave 8-2017 Rheumatoid arthritis Anxiety Pacemaker/Defibrillator Wave 11- 2019 Otitis Sickle cell Dermatitis/Urticaria Tonsillectomy Cardiac arrhythmia Kidney & urinary tract stones Breast cancer (multiple) Hernia procedures Other respiratory infection Coronary artery disease & angina Epileptic seizure Colon cancer Hypotension/Syncope Anal procedures Bipolar (multiple) Hemophilia & other coag. disorders Conduct disorder

TennCare Episodes of Care “Reconciliation”

How will we know our performance?

How will we support this work? Office of Episodes of Care aligned with PCC roles Analyst Director Project Manager(s) Project Coordinator Quality Finance Ad hoc services- i.e. HITS PCC Centered Resources Systems Engineering Admin Lead PCC Physician Lead Physician Content Experts Operational Leaders Finance Analyst Quality