1. Payment for Healthcare Alignment with Safety, Appropriateness, and Quality Accountable Payment Model Subgroup Bree Collaborative Meeting May 29, 2013

2. Members of the Subgroup Staffed by Rachel Quinn and Kathryn Bergh Providers 1. Bob Mecklenburg, Virginia Mason, Chair 2. Joe Gifford, Providence 3. Tom Hutchinson, WSMA/WSMGMA 4. Gary McLaughlin, Overlake Purchasers 1. Kerry Schaefer, King County 2. Jay Tihinen, Costco Health Plans 1. Bob Herr, Regence 2. Rich Maturi, Premera Quality Organizations 1. Susie Dade, Puget Sound Health Alliance 2. Julie Sylvester, Qualis Others: five orthopedists, including chair of State Association, a health plan orthopedist designee, and three orthopedist reviewers chosen by WSMA 2

3. Overview of Process The Accountable Payment Model Subgroup was formed by the Potentially Avoidable Readmissions Workgroup Task: develop warranty and bundled payment model Focus: total knee and total hip replacement surgery Goals for today’s presentation: 1.Review sources used to develop draft warranty 2.Receive feedback on current draft 3.Secure approval to submit draft for public comment 4.Provide update on a standards for appropriateness, a bundled payment model, and measures of quality 3

4. Four Deliverables Standards for appropriateness Surgical bundleWarranty Measurements of quality 4

5. 1. A Warranty for TKR and THR Aligning payment with safety 5

6. Current State Payment Misaligned with Safety 6

7. Warranty Aligning Payment with Safety “…accepting responsibility for defects or liability for repairs over a specified period” - Oxford English Reference Dictionary “no payment for readmissions related to complications attributable to surgery” - Accountable Payment Model Subgroup 7

8. Warranty for TKR and THR Four Sources Guided Design CMS data set for TKR and THR 1.Technical Expert Panel (TEP) defined complications, frequency, timing, and codes a. 12 member group included providers, patients, health plans, and consultants b. Supported by 10 member Yale Core Team with technical expertise in measures c. Supported by 6 member Working Group of 6 orthopedic content experts 2.Dartmouth’s High Value Healthcare Collaborative has adopted TEP definitions a. 19 medical centers across US plus Department of Defense b. Population base of 70-100M patients c. Grant from Center for Medicare and Medicaid Innovation Data sets from Medicare FFS and Premera Bundle payment pilots in California and Wisconsin CMS bundled payment initiative 8

9. General Content of Warranty Complications included in warranty: 1. Represent significant complications attributable to TKR/THR procedures 2. Are identifiable in administrative claims data 3. Are fair to hospitals and physicians 9

10. Specific Content of Warranty Adults with TKR and THR surgery Periods of accountability are complication-specific 7 days a. Acute myocardial infarction (heart attack) b. Pneumonia c. Sepsis (serious infection that has spread to bloodstream) 30 days a. Death b. Surgical site bleeding c. Wound infection 90 days a. Mechanical complications related to surgical procedure b. Periprosthetic joint infection (infected implanted joint) 10 year warranty on disruption of the integrity of the joint prosthesis itself- attributable to provider Hospital/provider group performing original surgery is accountable for payment for care of complications treated in another facility 10

11. Next Steps APM subgroup will meet tomorrow (May 30, 2013) to finalize warranty based on Bree edits We propose posting draft warranty on the Bree website for public comment the first two weeks of June We propose asking partners to announce this public comment period – HCA provider listserv, WSHA, WSMA, KC Med Society, and other orthopedic or interested groups We will bring revised warranty to the July meeting for adoption Today’s action step for Bree Collaborative: approve posting the draft warranty for public comment 11

12. 2. Standards for appropriateness Avoiding unnecessary surgery 12

13. Standards for appropriateness: Disability and Fitness for Surgery 1. Disability: reduced function and pain due to osteoarthritis despite conservative therapy Document disability on standard scale Document osteoarthritis on standard scale Document explicit conservative therapy for at least 3 months Document failure of conservative therapy on standard scale Evidence appraisal is complete Standards for appropriateness Surgical bundleWarranty Measurement of quality 13

14. 2. Fitness for surgery: physical preparation and patient engagement Document adherence to safety standards regarding weight control, diabetes control, smoking Document patient engagement: shared decision-making Specify care partner that assists patient throughout Document standard preoperative evaluation for surgery Virginia Mason is appraising evidence for these items Standards for appropriateness Surgical bundleWarranty Measurement of quality 14

15. 3. Surgical Bundle Transparent components of quality 15

16. Surgical Bundle: Surgical Repair and Return to Function 1. Surgical repair Credentialing and standards for a surgical team Standards for optimal anesthesia Standard process for avoiding infection Standard process for avoiding bleeding Standards for avoiding thrombosis and embolism (blood clot in lung) Standards for maintaining optimal blood sugar Standards for selection of the surgical implant Standards for appropriateness Surgical bundleWarranty Measurement of quality 16

17. 2. Return to function Standard process for post-op care in the hospital Standardized hospital discharge process from WSHA/Alliance/Qualis tool kit Standard process for arranging home health services Standard process for scheduling follow up appointments Standard process for measurement of functional outcomes Evidence appraisal is not complete for above elements Standards for appropriateness Surgical bundleWarranty Measurement of quality 17

18. Intent is to bring completed clinical bundle to July meeting Are health plans willing and able to administer warranty and bundles? If so, what is the timeline? Standards for appropriateness Surgical bundleWarranty Measurement of quality 18

19. Progress with Deliverables Direction from the PAR WorkgroupProgress of the APM Workgroup Recommend episodes of focusCompleted – Selected total hip and knee replacement surgeries. Recommend warranty definitionCompleted – Presented at today’s meeting. Recommend bundleIn progress – Evidence appraisal of draft content is underway. Recommend payment process Prospective vs. retrospective Unbundling guidelines Not started Recommend implementation timelineCompleted – Recommend implementation by 1/1/2014. Define quality outcome measuresIn progress – See next slides. 19

20. 4. Measurement of Quality The guide to purchasing 20

21. Group has discussed 5 broad categories of measures: 1. Patient satisfaction 2. Evidence-based care 3. Functional improvement (Pre- and post-operation) 4. Avoiding readmissions 5. Others, such as time to return to function Warranty Standards for appropriateness Surgical bundle Measurement of quality 21

22. Quality measures currently under consideration: 1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey as indicator of patient care experience 2. HOOS/KOOS and/or PROMIS-10 as indicator of improved function Any recommendations for other indicators to consider? Standard for appropriateness Surgical bundleWarranty Measurement of quality 22

23. 23 Safety Appropriateness Quality Affordability Accountability