1. Episodes of Care
TennCare Episodes

2. 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

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

4. 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

5. 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 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.

6. 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:
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:
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

7. 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:
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

8. 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:
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:
Gastrointestinal
Hemorrhage
A diagnosis for GI
Hemorrhage.
Facility where the GI
Hemorrhage was treated.

9. 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:
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:
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:
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.

10. Tenn Care- Episodes of Care Baseline Periods
Wave (performance start 1/2017)
Wave
Wave
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
Wave
Wave
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
Schizophrenia (multiple)
Fluid electrolyte imbalance
Breast biopsy
Medical non-infectious orthopedic
GI obstruction
PTSD
Wave
Rheumatoid arthritis
Anxiety
Pacemaker/Defibrillator
Wave
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

11. TennCare Episodes of Care “Reconciliation”

12. How will we know our performance?

13. 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