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. TennCare – Episodes of Care Baseline Periods
Wave 1
(performance start 2015)
Acute Asthma Exacerbation
Perinatal
Total Joint Replacement
Wave 3
(performance start 2017)
GI Hemorrhage
Simple Pneumonia
Respiratory Infection
Upper GI Endoscopy
UTI - Inpatient
UTI – Outpatient
Wave 5
(performance start 2018)
Anxiety
Tonsillectomy
Non-emergent Depression
Mastectomy
Breast Biopsy
Breast Cancer
Otitis Media
Wave 2
(performance start 2016)
Acute COPD Exacerbation
Colonoscopy
Cholecystectomy
Acute PCI
Non-Acute PCI
Wave 4
(performance start 2017)
ADHD
Bariatric Surgery
CABG
CHF Acute Exacerbation
ODD
Valve Repair/Replacement
Wave 6
(performance start 2018)
Skin & Soft Tissue Infection
Neonatal
HIV
Pancreatitis
Diabetes Acute Exacerbation

7. TennCare – Episodes of Care Baseline Periods
Wave 7
(performance start 2019)
Spinal Fusion
Spinal Decompression (w/o spinal fusion)
Femur/ Pelvic Fracture
Knee Arthroscopy
Ankle/Wrist/Shoulder/Knee non-operative Injuries
Back/ Neck Pain
Wave 8
(performance start 2019)
Acute Seizure
Syncope
Hyponatremia/ Dehydration
Pediatric Acute Lower Respiratory Infection
Colposcopy
Hysterectomy
GI Obstruction
Appendectomy
Hernia Procedures
Wave 9
(performance start 2020)
Conduct Disorder
Lung Cancer (multiple)
Colon Cancer
Female Reproductive Cancer
Liver & Pancreatic Cancer
Drug Dependence
Wave 10
(performance start 2020)
Sickle Cell
Renal Failure
Other Major Bowel (multiple)
Hepatitis C
GERD Acute Exacerbation
Kidney & Urinary Tract Stones
Hemophilia/ Coagulation Disorders
Rheumatoid Arthritis
Wave 11
(performance start 2021)
Schizophrenia (multiple)
Bipolar
PTSD
Anal Procedures
CAD & Angina
Cardiac Arrhythmia
Depression – Acute Exacerbation
Pacemaker/ Defibrillator
Dermatitis/ Urticaria

8. Mandated Populations- TennCare Populations in Wave 1
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

9. Mandated Populations- TennCare Populations in Wave 2
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

10. Mandated Populations- TennCare Populations in Wave 3
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.

11. Mandated Populations- TennCare Populations in Wave 4
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.

12. Mandated Populations- TennCare Populations in Wave 5
Episode
Trigger(s)
Quarterback
Start Time
Quality Metrics
Anxiety
A diagnosis of anxiety.
Provider with the plurality of visits for anxiety during the episode window.
Day of triggering diagnosis
5 visits/claim minimum during the episode window, patients under 18 filling at least one Rx for benzodiazepines
End Time
Age: 7 – 64
179 days after triggering diagnosis
Tonsillectomy
A tonsillectomy and/or adenoidectomy procedure
The clinician or group performing the procedure
Dexamethasone administered during trigger window (higher is better), Post-op bleeding during the trigger window and up to two days afterward (lower is better)
30 days prior to procedure
Age: 6mo – 20yo
30 days after discharge
Non-Emergent Depression
A diagnosis of depression or anxiety.
The provider with the plurality of visits for depression and anxiety during the episode window.
Mastectomy
An inpatient admission, observation stay or ER/outpatient visit
Partial mastectomy rate, surgical complication rate and timely clinical registry reporting
Age: 13 – 64
Breast Biopsy
An inpatient admission, observation stay, outpatient or office visit
Appropriate diagnostic workup rate and core needle biopsy rate
90 days prior to procedure
Breast Cancer Medical Oncology
A professional or pharmacy claim with antineoplastic therapy
The provider with the plurality of therapy infusion administrations or the provider with plurality of related visits
Timely clinical registry reporting
Day of initial antineoplastic therapy
179 days after antineoplastic therapy
Otitis Media
An outpatient hospital, emergency department or office visit
The provider or group who diagnosed the otitis media
OME episodes without antibiotics filled and non-OME episodes with amoxicillin filled
30 days after trigger event

13. Mandated Populations- TennCare Populations in Wave 6
Episode
Trigger(s)
Quarterback
Start Time
Quality Metrics
Skin and Soft Tissue Infection
An office, urgent care center, or emergency department visit
The provider or group who diagnosed the SSTI
Day of triggering diagnosis
Bacterial cultures when incision and drainage (I&D) performed and SSTI episodes with a first-line antibiotic
End Time
Age: 1mo – 64yo
30 days after end of trigger event
Neonatal
(Age 31 weeks or less)
An inpatient admission
The facility where newborn was delivered
Newborn hearing screen, critical congenital heart disease screen, blood spot screen, hepatitis B vaccine and participation in Vermont Oxford Network
Day of live birth
Age: <64
7 days after discharge
(Age 32 to 36 weeks)
Newborn hearing screen, critical congenital heart disease screen, blood spot screen, hepatitis B vaccine
(Age 37 weeks or greater)
HIV
A pharmacy claim with HIV-specific antiretroviral therapy medication
The provider with the plurality of related visits
Periodic ART refill and viral status reporting
Day of pharmacy claim
Age: 1 – 64
179 days after pharmacy claim
Pancreatitis
An inpatient visit or observation claim
Facility where patient was treated
Follow-up care and nutritional counseling
Day of hospitalization
30 days after discharge
Diabetes Acute Exacerbation
Follow-up care and diabetes counseling

14. TennCare Episodes of Care “Reconciliation”

15. How will we know our performance?

16. 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