navigating multi-hospital, episode-based care delivery · 4 •assess episode-based care delivery...

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Session 284, February 14, 2019 – 4-5 pm

Jennifer Waterbury, MSIE, CSSBB, Senior Bundled Payment Engineer, AdventHealth

Mark Hiller, Vice President of Bundled Payment Collaborative & Analytics, Premier Inc.

Navigating Multi-Hospital, Episode-Based Care Delivery

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Jennifer Waterbury, Senior Bundled Payment Engineer, AdventHealth

Mark Hiller, Vice President of Bundled Payment Collaborative & Analytics, Premier Inc.

Conflict of Interest

Have no real or apparent conflicts of interest to report.

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• Review Episode-Based Models and Analytics

• Collaboration & Data

• Refacing of BPIP Interface Data

• Internal Analytics Tool

• Outcomes

• Future Applications

Agenda

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• Assess episode-based care delivery modeling for a total joint bundled payment program

• Identify analytics capabilities, education, training and process improvements needed across multi-hospital teams

• Discuss claims analytics data optimization for bundled payment program

• Recognize challenges with limited data that led to development of a real-time internal bundled payment analytic tool

• Restate the benefit of standardized data and analytical support for a multi-hospital organization to achieve success with bundled payments

Learning Objectives

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Different Types of Data

• Blinding of Information Varies by Payer and Even Type of Contract – Paid Amounts, Provider Blinding Challenges

• No Standard Reliable Format to Payer Claims Files – Mapping Necessary for Each New Program

• File Timing and Format Changes Inconsistent

• Federal Program Files Usually Most Transparent – Ideal Starting Files

• Claims-based Information May Differ from EHR/HIE Sourced Data – e.g. Mammogram Rate

• Claims Lag – Balance “Complete” with “Timely”

• Cost Information From Outside May Need to be “Siloed”

Different Set of Skills/Expertise

• Management of Changing or Absent Attribution in Populations

• Creation of Actionable Information from Overwhelming Data – “Bigger Haystack”

Claims Analytics Challenges

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Awards

• 2017 Bundled Payment Collaborative Member Awards

– Bundled Payment Intelligence Platform Super User Award

– Member Sharing Masters Award

• 2018 Healthcare Informatics Innovator Award – 2nd Place

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Episode-Based Models

Comprehensive Care

for Joint Replacement

(CJR)

Bundled Payments for

Care Improvement

(BPCI) – Advanced

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Episode-based Care/Payment includes:

• Full continuum of care from episode start through care transitions

• Incentives for improving efficiency and care coordination

– Clinical Outcomes

– Financial Accountability

Episode-Based Analytics

Anchor

Hospitalization

(Episode

Initiator)

Anchor

Hospitalization

(Episode

Initiator)

Physician Fee

Schedule

Physician Fee

ScheduleSNF/IRF/LTCHSNF/IRF/LTCH

Home Health/

Outpatient

Services

Home Health/

Outpatient

Services

ReadmissionsReadmissions

90 days

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Comprehensive Care for Joint Replacement

CJR: mandated model for Medicare hip & knee replacements

• Started April 2016 and continues through December 2020

• Episode: Anchor Admission through 90 days post discharge

• Target & Actual spend includes all costs (some exclusions apply)

• Reconciliation/Repayment

• Revised Dec 2017 reducing mandated Metropolitan Statistical Areas

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• Original rule: 16 hospitals within 4 states

• No prior orthopedic bundled payment experience

– Joint Programs at some facilities

• Corporate Support and Standardization needed

– Engage with physicians, executives

– Care Coordinators, Program Managers

– Timely comprehensive data

CJR and AHS

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Data Challenges

• AHS Internal Dashboard Limitations for THA/TKA

– Only displayed 30-day readmissions

– Not tracking complication rate

– Not tracking post-acute care

• CMS data over a year old

– 3 years combined

– Multiple baseline files

– Not user friendly

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Medicare Claims Data Challenges

IPHDR File

EPI File

Have to link from IPHDR to EPI by EPI_ID

• Look at the Anchor_OP_NPI to determine the physician

– Must have a NPI list with physician names

• For patient name: use BENE_SK and BENE_HIC_Num in the DENOM file

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Overwhelming!!!

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Additional Issues

• Download of multiple files with each publication

• Incomplete due to Claims Lag

• Medicare data only published quarterly (originally)

– Now monthly

• Quality metrics not included

Medicare Claims Data Challenges

How do we know in real-time how we are performing?

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Collaboration and Data

• AHS joined Premier’s Bundled Payment Collaborative Sept. 1, 2015

• Collaborative provided access to the Bundled Payment Intelligence Platform (BPIP)

– Bundled payment specific cross continuum claims analytics for CJR

– Became available and trained users in June 2016

• Additional efforts:

– Bi-weekly Project Status meetings to review the progress of the Comprehensive

Care for Joint Replacement (CJR) program

– Attendance at AHS Steering Committee meetings

– Gainsharing Analytics Platform (GSAP)

– AHS team serves as one of the leading examples of success for other members of the collaborative

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CJR Reporting Interface

User Friendly By Hospital and By Physician Claims Data

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CJR Reporting Interface

This allowed us to not

have to struggle with the

Medicare claims files

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AdventHealth CJR Financials

Performance

year 2

Performance

year 2

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AdventHealth CJR Post-Acute Care

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AdventHealth CJR Patient Tracking Dashboard

Dashboard to display near real time data for key metrics:

Calculator for predicting episode total spend, depending upon patient type and PAC services utilized

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• Electronic Medical Record (EMR)

• Data team member(s) with understanding of multifaceted layers of CJR

• Access to advanced data analytic tools and developer

• Collaborative Team

• Engaged Hospital CJR Program Owners

Prerequisites

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• Approval from Steering Committee

• Collaborated with leadership and CJR sites to identify key metrics

• Identify sources for data using EMR whenever possible

• Mirror criteria and timeframes from CJR Regulations and Quality Metric specifications

• Weekly meetings with the analytics team

• Enhanced analytic team’s knowledge through a CJR site visit

• Piloted to hospitals for feedback prior to production

• Continue collaboration with analytics team for further enhancements

Development Process

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Executive Summary

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Patient Details

Drill down to patient specific data combined from EMR and manually submission

Care Navigator data to capture readmissions to facilities outside of AHS

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Beneficiary Letter

Presence of scanned in

Beneficiary Letter

captured in EMR

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Complications

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Care Coordinator Data

Collected and submitted by each hospital’s CJR Care Coordinator

Uploaded to secure FTP site for the dashboard to easily access

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Cost Prediction Calculator

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CJR Patient Tracking Dashboard

• Go-Live

– Early 2017 (PY2)

• Data is refreshed daily

• Continual training and ad hoc phone calls

• Share standardized data at meetings

How does this benefit a multihospital organization?

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• THA/TKA Complications

– Dashboard provides up to date knowledge, instead of 2 years behind

– Developed a Performance Improvement Project

– Identified opportunity with pneumonia complications and a correlation with higher BMI

– Strengthening system for patient optimization

• Raw Complication within AHS facilities only

– PY 2 (FY): 3.2%

– PY 3 to date (~6-8 months): 1.5%

• Received reconciliation payment for PY 1 and PY 2

• PY 1 & PY 2 Quality was in “Good” category and are aiming for “Excellent”

Hospital A

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• Return to Hospital

– Dashboard provides up to date ED visits, Observation statuses, and Readmissions to our own facilities

– Analyzed the reasons for return visits to see if there was consistency and identified constipation

– Identified opportunity in education

• Beefed up pre-op class

• Going through the over the counter medications

• Raw readmissions to AHS facilities

– 2017 discharges: 18%

– April-July 2018 discharges: <10%

• Received reconciliation payment for PY 1 and PY 2

• PY 1 and PY 2 quality score categories are “Good”

Hospital B

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• Use dashboard to estimate the potential costs/spend of patient while keeping the best outcomes in mind

– Optimize post-acute care placement

• Raw Complication within AHS facilities only | Total Claims

– 470 without fracture

• PY 1: 5.9% | $23,156

• PY 2: 0% | $22,110

• Received reconciliation payment for PY 1, projecting reconciliation payment for PY 2

– PY 1 Quality was in “Acceptable” category

Hospital C

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PY2

• Reconciliation payment was an excess of $1.8M

– All 12 CCNs received reconciliation

• Quality

– 4: Excellent 6: Good 2: Acceptable

PY1 compared to PY2 (6 months of each)

• 13-17% decrease in acute hospital LOS

• 19% decrease in 90-day readmissions

• 17% decrease in SNF discharges

Bi-Monthly calls to review performance including data

AdventHealth CJR Outcomes

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Success, but Still Improving

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BPCI-Advanced

• CMS released on January 9th, 2018

• Voluntary model

• 29 inpatient and 3 outpatient clinical episodes

• CJR takes precedence

• Hierarchy: Attending, Operating, then Hospital

• Effective Oct 1, 2018 through December 31, 2023

• 90 day post discharge episodes (like CJR)

• 20% stop loss/stop gain out the gate (not like CJR)

• Quality metrics

• All-cause Hospital Readmission Measure (NQF #1789)

• Advanced Care Plan (NQF #0326)

• Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)

• Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)

• Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)

• Excess Days in Acute Care after Hospitalization for Acute Myocardial Infraction (NQF #2881)

• ARRQ Patient Safety Indicators (PSI 90)

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• Challenges: Data complexity and lag

• Automate data from EMR, as much as possible

– Standardized, actionable, near-real time CJR dashboard has benefited our sites

• Involve clinical end-users to identify key metrics

• Build strong analytics team

– Site visit with data analytics team

– Validation and ongoing refinement

• Beta-testing to identify glitches and make adjustments

• Sharing best practices through a continual feedback loop

– Decreased complications and readmissions

– Collaboration across the system

Summary

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Jennifer Waterbury, MSIE, CSSBB

Sr. Bundled Payment Engineer

AdventHealth

407-357-3079

Jennifer.Waterbury@AdventHealth.com

Mark Hiller

Vice President of Bundled Payment

Collaborative & Analytics, Premier Inc.

704-816-5157

Mark_Hiller@PremierInc.com

Questions

Please attend

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