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Episodes of Care TennCare Episodes
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Market and Regulatory Environment:
Future Value-driven, Coordinated Care Delivery System Changes Care Coordination Provider Feedback & Accountability Measurement around Quality & Efficiency Hospital-Acquired Conditions Penalties HITECH/ Meaningful Use Penalties TennCare Bundles Optional Commercial Bundles Insurance Exchanges open 2016… 2015 2014 2013 2012 …2011 Individual coverage Requirement Disproportionate Care reductions CMS Bundled Payment Pilot DRG Readmissions Penalties Value-Based Purchasing Incentives HITECH/Meaningful Use Incentives CMS Community Care Transition Program Today Volume-driven, Fragmented Care Fragmented event driven care Payment System Changes Fee-for-Service Episode or Comprehensive Care Payment Clinical Integration
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Current Episodes of Care
Mandated Timelines Identified Evaluating Other episodes *CMS indicating Mandated Bundles in the next 2-3 years
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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
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What does an Episode of Care Payment Model look like
What does an Episode of Care Payment Model look like? How does it create shared risk? Episode of Care Professional Services Inpatient Professional Outpatient Professional Facility & Other Services Index Hospitalization Post-Acute: Rehab, Home Episode anchor: Admission at awardee hospital for included clinical condition – reason for admissions 3-day pre-admission Readmission End of Episode: d, or > 90d Who’s accountable: Physician OR Organization Accountable For: Quality Outcomes and Cost against Target price What’s at Risk: Revenue; Public Reputation; Volume How: Traditional FFS with reconciliation process
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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 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 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 90 days after discharge date
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TennCare Episodes of Care “Reconciliation”
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How do we determine a population?
Populations will be mandated TennCare Bundles are starting to roll out with Pediatric Asthma, Perinatal, and Total Joint Replacement We can choose populations Medicare is allowing initiators to sign up on any of 47 “episodes” in 4 different Models Medicare or Commercial We can create populations Internal data can be used to look at opportunities Increase margin, decrease variation i.e. Center of Excellence, Destination Centers
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Internal Margin/ quality enhancement Clinical Redesign efforts
Population selection and Clinical redesign efforts 1: Setup 2: Analyzing and Initiating 3: Developing Interventions 4: Testing 5: Hardwiring Successes 6: Monitoring & Sustaining Exec Sign off TennCare Medicare Commercial Internal Margin/ quality enhancement Clinical Redesign efforts Wave 1 Asthma X Phase 5 Total Joint NOSA Phase 4 Perinatal Cigna On hold Wave2 Colonoscopy Deferred Cholecystectomy Percutaneous Coronary Intervention COPD Internally Identified Pneumonia Spine ? Valve Surgery Phase 6
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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
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How will we know our performance?
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What is the timeline?
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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
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