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Comprehensive Care for Joint Replacements (CCJR)

Proposed Rule Overview

Janis Orlowski, MD Coleen Kivlahan, MD Jessica Walradt, MSAAMC Health Care Affairs: Alternative Payment TeamAugust 6, 2015

Agenda

1. Why BPCI Matters: CCJR and AAMC’s Experience

2. CCJR Rule Overview3. Q&A4. Bundling 101 Boot Camp: Succeeding at CCJR

3

BPCI OverviewIssue BPCI CCJR

Program duration 3 years (Ends by Sept. 30, 2018)

5 years (Jan. 1, 2016 - Dec. 31, 2020)

Baseline period FY 2009 - 2012Fixed

CY 2012 - 2014Rolling; rebased every other

year

Target price 100% hospital specific historical data

Blend of hospital-specific and regional historical data

Episode duration 90 days 90 days

Quality measures N/AMust meet threshold on 2

quality measures to qualify for savings

Gainsharing Gainshare ICS and NPRAGainshare ICS and NPRA

Can share downside risk with other providers

Beneficiary data Cannot opt out of having their data shared

Can opt out of having their data shared

Data sharing Data provided prior to go-liveMonthly updates

Hospitals must request dataData provided 60-days post-

go-liveQuarterly updates

4

AAMC as Facilitator Convener

Learning Collaborative Advocacy Policy Analysis Data and Clinical Analyses Project Management

5

AAMC’s BPCI Health Systems

Indiana

Michigan

California

Nevada

Oregon

Washington

Arizona

Utah

Idaho

Montana

Wyoming

Colorado

New Mexico

Nebraska

MaineVermont

New York

North Carolina

Georgia

South Carolina

Alabama

Mississippi Louisiana

Texas

Pennsylvania

Wisconsin

Minnesota North Dakota

Ohio

West Virginia

South Dakota

Arkansas

Missouri

Iowa

Illinois

Tennessee

Kentucky

DelawareNew Jersey

Connecticut

MassachusettsNew Hampshire

Virginia Maryland

Rhode Island

District of Columbia

Kansas

Oklahoma

Current Participants

July 2015

Florida

6

AAMC BPCI Episodes

• Major joint replacement - lower extremity (19)• CHF (7)• CABG (5)• Cardiac valve (4) • Stroke (4)• Cervical spinal fusion (3) • COPD (3) • Spinal fusion (non-cervical) (3)• Double joint replacement - lower extremity (3)• Major bowel procedure (2)

Live as of October 1, 2015

7

BPCI LEJR Experience: Risk and Opportunities

LEJR Savings range from 0.3% to 12% of target amount Opportunities: Over 80% of payments occur in the first 30 days, with 50% of total

payments in the index admission Major savings opportunity: post-acute care. Partnership with PAC

providers Evidence-based care process map for elective joint procedures Generate internal cost savings (ICS); gainsharing option engages

physician partnersChallenges: The efficient provider Hip fractures, non-elective joint replacement

8

CCJR Participation

9

Does this program apply to me?

COTH Non-COTH

Major TeachingNon-COTH

Minor TOTAL - ALL

TEACHINGTotal Hospitals 239 131 690 1,060 Total Hospitals in CCJR MSAs 94 61 243 398 % in CCJR MSAs 39% 47% 35% 38%Total in BPCI (April 2015) 45 18 96 159

Live with BPCI (Phase II) 20 8 27 55 Live with MJRLE 10 5 12 27 Phase I Only 25 10 69 104

Table 1. Hospitals in CCJR

75 out of 388, or 20% of, MSAs selected

10

How did CMS select the 75 MSAs?

Start with 388 MSAs Eliminate MSAs based on LEJR volume and

BPCI LEJR market saturation Random stratification

1. MSA average wage-adjusted historic LEJR episode payments; and

2. MSA population size

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COTH Hospitals in CCJR MSAs

12

Hospitals Excluded from CCJR

Hospitals not located in an MSA selected for CCJR

Maryland hospitals Hospitals not paid under IPPS (CAHs) Hospitals at-risk for lower extremity joint

replacements (LEJRs) in BPCI for the duration of their BPCI performance period

13

CCJR Beneficiaries

CCJR Patient Eligibility Criteria: Medicare must be the primary payer Enrolled in Part A and B throughout the episode Does not have ESRD Not enrolled in any managed care plan Not covered under United Mine Workers of America health planBeneficiaries must be notified of the CCJR Model Unable to opt out of CCJR program – can change provider remains Can opt out of data sharingBeneficiary CCJR episode will be cancelled if: Beneficiary dies during anchor hospitalization Beneficiary initiates episode under BPCI Acute care readmission discharge is under DRG 469/470 (the first

episode is dropped and a new episode is initiated)

14

CCJR Episode Definitions

15

What is a CCJR bundle?

Anchor DRGs 469 and 470 Part A and B All cause readmissions with limited

exclusions Index hospitalization + 90 days post-

discharge Retrospective reconciliation

16

Exclusions

17

Payment Methodology

18

Payment Methodology Overview

Retrospective payment methodology Providers bill and receive reimbursement via current FFS structure At completion of the performance year, actual aggregate episode

claim payments are compared against the episode target priceTwo-sided risk model Hospitals may receive a reconciliation payment if actual spending is

less than the target Certain quality measure thresholds must also be met

Hospitals are responsible for paying Medicare if actual spending is greater than the target

No downside risk in performance year 1Phased-in approach is used for downside risk inperformance year 2Full downside risk in performance years 3 through 5Must meet quality thresholds to be eligible for payment

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How will the target price be calculated?

3 year baseline period DRG-specific Exclude special Medicare payments (IME, DSH, P4P)

from target price and performance period Normalize for wage index

Trend to performance

period $Trend

factor = 1.01

Baseline average episode

payment = $28,000

Apply 2% discount

factor$28,280

Performance period target

price = $27,714

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CCJR Target Price

1 2 3 4 5

2/3

1/3

Savings

Losses N/A 1%

CY 2016 - 2018Baseline Period

1/3

2/3

0%

100%

CY 2012 - 2014 CY 2014 - 2016

2%

2%

Performance Year

Regional Data

Hospital-specific Data

Discount Factor

Target Price Components

21

Target Prices: Regions

Source: http://www.eia.gov/consumption/commercial/censusmaps.cfm.

22

How will reconciliation work?

All providers continue to be paid FFS Aggregate performance period FFS payments

retrospectively reconciled against target amount Savings impacted by quality scores

Target price Episode Count

Target Amount

Actual FFS Payment

Medicare Savings/Losses

DRG 469 $40,000 20 $800,000 $1,100,000 ($300,000)

DRG 470 $25,000 400 $10,000,000 $8,000,000 $2,000,000

Total 420 $10,800,000 $9,100,000 $1,700,000

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What risk protection does my hospital have in CCJR?

1 2 3 4 5

Discount Factor for Calculating Losses No downside risk 1%

Cap on Losses(% of Target Amount) No downside risk 10%

Performance Year

2%

20%

Total 10% Uncapped CappedCounty General

Hospital $30,000 $30 $900,000 $90,000 (110,000)$ (90,000)$

Target Amount Medicare Savings/LossesTarget

PriceEpisode Count

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High Episode Payment Ceiling

Each episode is capped at 2 standard deviations above mean

25

High Episode Payment Ceiling

– Mean – 2 SD

Hospitals not responsible for payments above red line

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Quality Requirements

27

What quality measures does my hospital need to meet?

• CCJR hospitals must meet quality performance thresholds to be eligible for reconciliation payments

• Three measures proposed (performance must meet threshold for all measures): o Total Knee Arthroplasty (TKA)/Total Hip Arthroplasty (THA) 30

day Readmissionso TKA/THA 90 day Complicationso Hospital Consumer Assessment of Healthcare Providers

(HCAHP) Survey• CMS plans to use existing measure rates posted on Hospital

Compare• Hospitals that voluntarily submit THA/TKA patient-reported

outcomes measure would be eligible for a lower discount percentage used to set the target priceo This measure has not yet been developedo CMS seeks feedback on other ways to reward voluntary

reporting28

Background on Proposed Quality Measures

Measure NQF #

Patient Population Data Collection

Period

Minimum Volume

Threshold

Additional Details

THA/TKA Complications

1550 FFS beneficiaries admitted to an acute care facility and having a qualified elective primary THA/TKA procedure

3 years Minimum of 25 cases

Measure does not capture partial hip arthroplasty procedures (included in DRGs 469 & 470)

THA/TKA Readmissions

1551 FFS beneficiaries admitted to an acute care facility and having a qualified elective primary THA/TKA procedure

3 years Minimum of 25 cases

Measure does not capture partial hip arthroplasty procedures (included in DRGs 469 & 470)

HCAHPS(patient experience)

0166 Hospital patients at least 18 years of age

1 year 100/surveys a year

HCAHPS scored using linear mean roll-up (same calculation as the HCAHPS star ratings)

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Overlap with Other Models

30

Overlap With Other Payment Models

Accountable Care Organization (ACO)• Hospitals participating in CCJR may also participate in an ACO• Beneficiaries in both programs: Will attribute Medicare savings

accrued during CCJR time period to CCJRBundled Payment for Care Improvement (BPCI)• Hospitals live with LEJR in BPCI remain in BPCI for duration of

BPCI performance period• Should Phase II participants terminate from BPCI – they are

required to participate in CCJR, if within a designated MSA• BPCI Model 2/3 LEJR episodes will take precedence over CCJR

episodes

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BPCI LEJR Episode Takes Precedence Over CCJR Episode

Hospital A

CCJR

Physician in BPCI PGP B performs the

procedure.

Patient X receives joint replacement at Hospital A. PGP B claims

episode.

Critical Implication: <20 CCJR episodes/baseline Target price = 100% regional data

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Analyzing Episode Data

33

How will I get episode data?

Must request data on or after start date (Jan. 1, 2016)

Will receive data within 60 days of request Summary claims data Beneficiary-level raw claims data

Updated quarterly Beneficiary opt-out

34

Waivers and Gainsharing

35

What waivers will be applied?

• Waive 3-day hospital stay for SNF payment requirement

• SNF rating must be > 3 stars• Maintain patient choice

SNF

• Waive “incident to” rule to allow post-discharge home visits

• Patient cannot be homebound• Maximum of 9 visits

Home Visits

• Waive geographic site and originating site requirements

• Cannot substitute for in-person HH services paid under Medicare HH benefit

Telehealth

36

Can the hospital share savings (and risk) with other providers?

Can gainshare Medicare savings and internal cost savings with “CCJR collaborators” Cap on gainsharing payments made to physicians = 50% of PFS payments for services furnished to CCJR

beneficiaries Can share downside risk with CCJR collaborators Cap on aggregate “alignment payments” = 50% of hospital's repayment amount due to CMS Cap on individual alignment payment = 25% of hospital’s repayment amount due to CMS

CCJR Collaborators

SNFs, HHAs, LTCHs, IRFs, PGPs, physicians, non-physician practitioners, and outpatient

therapy providers who directly furnish care to CCJR beneficiaries during an episode and/or participate in CCJR care redesign activities.

37

Questions

• Please use the Q&A panel located on the right hand side of your screen to submit your questions. Send to All Panelists.

38

AAMC Support• Convener for 27 teaching hospitals in BPCI

with predominance of joint bundles• Oncology bundle support• CCJR support:

• CCJR summary and comment letter• Learning modules: “What is episode based payment?” • Partners in CCJR data support• Bundling and CCJR boot camp• TJR recent literature and best practice tools• How to Bundle manual

39

AAMC Next Steps

40

AAMC Next Steps in CCJR SupportBundling 101 Boot Camp: Succeeding at CCJR

• October 9, at the AAMC headquarters in Washington, DC

Attendees can expect:• Guest speakers with bundling expertise in AMCs• Practical steps and templates to use in

CCJR/bundled payments at your organization• Your organization’s TJR bundle data report• Group work on key challenges in TJR bundles• Flash drive with full day’s slides

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To Join Us…

• Formal registration will open in late August, but we have limited the size, and it is first come, first served, so let us know ASAP.

• Bring several colleagues in finance, operations and clinical areas

• 5 scholarships for residents available to advance engagement in new payment models

• One day boot camp, intense 8AM-5PM• If interested, reserve spots now at

[email protected]

42

Appendix

43

How does CCJR compare to BPCI?Issue BPCI CCJR

Program duration 3 years (Ends by Sept. 30, 2018)

5 years (Jan. 1, 2016 - Dec. 31, 2020)

Baseline period FY 2009 - 2012Fixed

CY 2012 - 2014Rolling; rebased every other

year

Target price 100% hospital-specific historical data

Blend of hospital-specific and regional historical data

Episode duration 90 days 90 days

Discount factor 2%

2% w/ adjustments for year 2 and voluntarily submitting patient-reported outcome

measures

Trend factor Retrospectively set national trend factor

Prospectively set hospital-specific/regional trend factor

Risk track(s) Choice of 3; responsible for 20% of costs above threshold

1 track; not responsible for costs above threshold

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BPCI vs. CCJRIssue BPCI CCJR

Reconciliation

Performance quarter retrospectively reconciled (4x) 6 months following the end of

the quarter.

Performance year retrospectively reconciled (2x)

1 quarter after end of year.

Cap on savings/lossesUpside only in CY 2014.

Savings/losses capped at 20% of target amount.

Upside only in year 1. 20% cap on savings. 10% cap on losses in year 2. 20% cap on

losses in years 3 - 5.

Quality measures N/AMust meet threshold on 2

quality measures to qualify for savings.

Gainsharing Gainshare ICS and NPRA. Gainshare ICS and NPRA.

Can share downside risk with other providers.

Beneficiary data Cannot opt out of having their data shared.

Can opt out of having their data shared.

Frequency of data sharing

Data provided prior to go-live. Monthly updates.

Data provided 60-days post-go-live. Quarterly updates.

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