Compassion. Excellence. Reliability. Bundled Payments for Care Improvement Initiative (BPCI) & Comprehensive Care for Joint Replacement (CJR) in Home Health Ryan McElhinny, PT,MPT,OCS Director Accountable Care BAYADA Home Health

Compassion. Excellence. Reliability. Objectives Develop understanding of Bundled Payments for Care Improvement Initiative (BPCI) Develop understanding of Comprehensive Care for Joint Replacement (CJR) Introduce BPCI payment structure Home Health Considerations For BPCI Questions and Discussion

Compassion. Excellence. Reliability. Bundled Payment for Care Improvement Initiative Development ACA (Affordable Care Act) provided ability to implement changes to improve quality and efficiency Development of Center for Medicare and Medicaid Innovation Led to alternative payment models and initiatives –Accountable Care Organizations –Bundled Payment for Care Improvements –Value-Based Purchasing (VBP) Medicare goals for alternative payment models –30% of Medicare payments into alternative models by end of 2016 –50% of Medicare payments into alternative models by end of 2018 –Healthcare Payment and Learning and Action Network established to support these goals

Compassion. Excellence. Reliability. Poll Question How many of you feel that Medicare will reach their goal of 50% of payments will be tied into alternative payment models by the end of 2018? Yes No

Compassion. Excellence. Reliability. Bundled Payment for Care Improvement (BPCI) Bundled Payments for Care Improvement Initiative (BPCI) Healthcare organizations enter into payment arrangements that include financial and performance accountability for a designated episode of care –4 BPCI models Goals: –Improve coordination of care across providers –Improve quality of care to patients across providers –Align incentives with providers –Improve patient care and lower costs to Medicare

Compassion. Excellence. Reliability. Bundled Payment for Care Improvement (BPCI) sheets-items/ html

Compassion. Excellence. Reliability. Bundled Payments for Care Improvement Initiative (BPCI) Model 1 –Episode of care defined as inpatient stay in hospital Model 2 –Retrospective bundled payment –Actual expenditures reconciled against a target price –Inpatient stay and all expenditures for a 30, 60, 90 day post-acute episode Model 3 –Retrospective bundles payment –Actual expenditures reconciled against a target price –Initiated at SNF, IRF, LTCH or HH agency for 30, 60, 90 day episode Model 4 –Single prospective payment made to the hospital –Payment for entire inpatient episode and readmissions

Compassion. Excellence. Reliability. Bundled Payment for Care Improvement (BPCI) 2 Phases of implementation for Models 2, 3 and 4 –Phase 1 “The Preparation Period” CMS and participant prepare for implementation of financial risk Timeframe for HH to enter into the partnership HH may complete RFI (Request for Information) for acceptance into program –Phase 2 “Risk Bearing Implementation” Offered after comprehensive review by CMS Enter into risk bearing with potential of paying money back to Medicare Opportunity for gainsharing Waivers –Gainsharing –3 day hospital stay for SNF (Model 2) –Telehealth (Models 2, 3) –Post discharge home visit (Models 2,3)

Compassion. Excellence. Reliability. Benchmark

Compassion. Excellence. Reliability. Poll Question How many of you are currently participating in a bundled payment initiative? Yes No

Compassion. Excellence. Reliability. Poll Question Of you who are participating in a bundle payment initiative, how many of you are involved in a bundle for joint replacement patients? Yes No

Compassion. Excellence. Reliability. Comprehensive Care for Joint Replacement (CJR) Overview Start Date April 1, 2016 CJR will run through December 31,2020 First MANDATORY bundle from CMS Market Locations 67 MSAs hospitals chosen to participate Excluded if currently participating in BPCI for Lower Extremity Joint Replacement Diagnosis and Bundle Services MS-DRG 469 and 470 Include hospital stay & 90 days post discharge All Part A and B services

Compassion. Excellence. Reliability. CJR Participation April 1, 2016 start of the program –Hospitals continue to be at different stages of operationalization –RFI (Request for Information) process common for acceptance into the network –Program being overseen by various hospital employees C-Suite Director of case management Designated program leader

Compassion. Excellence. Reliability. Who is involved in partnership development? Marketing team –Marketing may be first to hear of CJR or BPCI opportunities –Marketing good resource to explore who managing the program Director, administrator, marketing director, owner –Move to establish a formal meeting with decision makers –Present agencies quality data and specifically joint performance data –Discuss prior and current success with the hospital –Understand goals of the hospital for the program Questions to ask initially –Are you aware of your hospitals participation in the CMS CJR program? –Who is making decisions about or leading your CJR initiative? –Who can I speak with to present quality/experience to participate in CJR? –Have you currently chosen home health providers for the CJR program? –What steps do I need to take to discuss my agencies participation in CJR?

Compassion. Excellence. Reliability. Payment Under the Bundle Hospital will be paid a “target price” calculated each PY –MS-DRG 469, 470 with adjustment for hip fracture CMS will apply a 1.5%-3% discount –Based on quality score Performance year 2 hospital responsible for downside risk –Repay Medicare for spending over target price

Compassion. Excellence. Reliability. Payment and Quality Hospital starts with a Target Price –20,000 with 3% discount = 19,400 –Perform 100 episodes that cost 18,000 –19,400x100= 1,940,000 vs 18,000 x 100= 1,800,000 –140,000 below the Target Price Hospital composite quality score –Hospital scores 15.0 or “Excellent” rating Hospital qualifies for reconciliation payment

Compassion. Excellence. Reliability. Payment and Quality Hospital starts with a Target Price –20,000 with 3% discount = 19,400 –Perform 100 episodes that cost 20,000 –19,400x100= 1,940,000 vs 18,000 x 100= 2,000,000 –60,000 above the Target Price Hospital composite quality score –Hospital scores 5.0 or “Average” rating Hospital does not qualify for reconciliation payment Hospital will have repayment starting in year 2

Compassion. Excellence. Reliability. Hospital Quality Measures Under CJR Composite Quality Score –THA/TKA Complications Measure Acute MI Pneumonia or sepsis/septicemia within 7 days of admission Surgical site bleeding, pulmonary embolism or death within 30 days Mechanical complications, prosthetic joint infection, wound infection within 90 days –HCAHPS Patient Experience Survey Measure –Submission of patient reported THA/TKA outcomes Hospital needs to submit data on at least 50% of patients

Compassion. Excellence. Reliability. Hospital Quality Measures Under CJR 4 categories for performance: –“Below Acceptable” –“Acceptable” –“Good” –“Excellent” Total 20 points –THA/TKA Complication-10 –HCAHPS-8 –PRO-2

Compassion. Excellence. Reliability. Reconciliation or Repayment Reconciliation payment –Hospitals that spend below the target price –Hospitals that meet the quality criteria –Combination of achieving quality threshold and cost efficiency Repayment –Hospitals that spend over the target price –Hospitals that do no meet quality criteria –Begins in PY 2 of the initiative

Compassion. Excellence. Reliability. Home Health Considerations For BPCI or CJR Evaluate your agencies quality scores –How do you compare to the competition? Evaluate your referral management process –How efficiently do you handle care transitions? Analyze your current utilization management –Are you confident that you can explain your revenue as it applies to utilization which is cost to the bundle? Develop a data reporting structure –Are you able to consistently reproduce data to discuss within the partnership? Educate all staff about the initiative

Compassion. Excellence. Reliability. Surgical Hip/Femur Fracture Treatment (SHFFT) Proposed rule introduced by CMS July 25, 2016 Add onto CJR in the 67 MSA’s currently participating Proposed to include DRG –DRG 480 Hip & Femur Procedure Except Major Joint with Major Complication or Comorbidity (MCC) –DRG 481 Hip & Femure Procedures Except Major Joint with Complication or Comorbidity (CC) –DRG 482 Hip & Femur Procedures Except Major Joint without CC/MCC Begin July 1, 2017 and run for 5 performance years

Compassion. Excellence. Reliability. Questions and Discussion This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-B1-7/