Changing Landscape of Long-Term
Care: Hospital Partnerships
Dan Rothery
President, BJC Home Care and Community Services
VOYCE Conference
June 8, 2017
Objectives
• Review changing payment landscape for healthcare organizations
• Understand a hospital system’s approach to preparing for the change
• Understand post-acute provider partnership opportunities with hospitals
• Understand the universal truth: Optimizing the care of patients by the
right place, the right time at the lowest cost.
• Understand how to get to: What’s in it for me?
2
Your Speaker
As president of BJC Home Care and Community Services, Dan Rothery
is responsible for BJC Behavioral Health, BJC Corporate Health Services
and BJC Home Care Services and a management relationship with
Bethesda Health Group for Barnes Jewish Extended Care, Eunice Smith
and Village North Incorporated as well as The Rehabilitation Institute of
St. Louis.
Rothery served as president of Boone Hospital Center in Columbia,
Missouri for six years prior to assuming oversight of BJC’s home care
and community services in 2013. Before joining Boone Hospital Center in
2006, Rothery led The Rehabilitation Institute of St. Louis, a joint venture
between BJC HealthCare and HealthSouth affiliated with Washington
University School of Medicine. Rothery also served as the interim chief
executive officer of HealthSouth’s Rusk Rehabilitation Center in
Columbia, Missouri.
For the past 25 years, Rothery has held executive positions in acute,
sub-acute, rehabilitation and home care environments at the Cleveland
Clinic Foundation, BJC HealthCare and St. John’s Mercy Medical Center
in St. Louis.
Rothery earned his master’s degree in hospital administration from St.
Louis University. He received his bachelor’s degree from Quincy
University in Quincy, Illinois.
Rothery is active in the community and has served on several local
boards. He is a native of St. Louis and is married with three children.
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CMS Quality Strategy
Goals:
• Make care safer
• Strengthen person and family centered care
• Promote effective communications and care coordination
• Promote effective prevention and treatment
• Promote best practices for healthy living
• Make care affordable
4
5
Value-Based Payments Replaces Fee for Service
• Value-Based Payments (VBP) pays for outcomes and not for the volume of
services
• Total cost of care for a population
• Must focus on the most complex individuals who:
– Drive most of the capital costs, and
– Get care in multiple sites from multiple providers
6
Value-Based Purchasing Links Quality and Risk on a Continuum
7
And Then, There is the IMPACT Act of 2014
• Bi-partisan bill introduced in March, U.S. House and Senate, passed on
September 18, 2014, and signed into law by President Obama October 6, 2014.
• The Act requires the submission of standardized assessment date by:
– Long-Term Care Hospitals (LTCHs): LCDS
– Skilled Nursing Facilities (SNFs): MDS
– Home Health Agencies (HHAs): OASIS
– Inpatient Rehabilitation Facilities (IRFs): IRF-PAI
• The Act requires that CMS make interoperable standardized patient assessment
and quality measures data, and data on resource use and other measures to
allow for the exchange of data among PAC and other providers to facilitate
coordinate care and improved outcomes
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
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Why IMPACT? Why Now?
• The lack of comparable information across PAC settings undermines the ability
to evaluate and differentiate between appropriate care settings for and by
individuals and their caregivers.
• Standardized PAC assessment date will allow for continued beneficiary access
to the most appropriate setting of care.
• Standardized PAC assessment data allows CMS to compare quality across PAC
setting (longitudinal data).
• Standardized and interoperable PAC assessment data allows improvements in
hospital and PAC discharge planning and the transfer of health information
across the care continuum.
• Standardized PAC assessment data will allow for PAC payment reform (site
neutral or bundled payments).
• Standardized and interoperable PAC assessment data supports service delivery
reform.
9
Achieving Better Care, Healthier People & Smarter Spending
Why Post-Acute Matters:
• 32,617 Post-Acute (PAC) Facilities
• 6.8 million Medicare Beneficiaries
• $74 billion Medicare Spending
• 14.8% of Total Medicare Spending ($500 billion)
• 420 Long-Term Care Hospitals (LTCH)
• 1,166 Inpatient Rehabilitation Facilities (IRF)
• 3,720 Hospices
• 12,311 Home Health Agencies
• 15,000 Nursing Homes
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BJC Landscape
11
BJC’s Approach to Bundles
• Now called “Episode Payment Models” (EPM)
• Establishes single price target for longitudinal care episode, often including
both acute care and post-acute care.
• Single price for episode drives the need to improve quality across entire episode
including care transitions and post-acute care
• Hospitals have financial and quality accountability for care episodes
• There is also the opportunity to share savings with clinical partners
• These models are anticipated to result in higher quality and more coordinated
care at lower cost.
12
Bundle Example: Costs across 90-day episode in
hip/knee replacement surgery (BPCI illustration)
CMS will set target prices for longitudinal episode of care (3d PTA to 90d post-D/C)
that initially blends hospital-specific and regional historic data, with CMS’s target
discount factor varying based on quality.
Distribution of spending per 90-day episode Major Joint MS-DRG 469-470 (2013)*
$24.77K
$12.7K
$1.7K
$7.2K
$3.2K
51.3%
6.9%
29.1%
12.8%
Index Admission
• OR Charges
• Facility Charges
• Transfer DRG Penalty
MD Pro
Fee
Post-Acute
Care (PAC)
Readmission
*Advisory Board Company, National Data, 2013
13
Current State of National Landscape
2014 Bundled Payment
for Care Improvement
(BPCI)
• Voluntary
• 48 potential clinical areas
• Most common bundles:
LEJR, CHF, COPD
• ~1500 participants
(hospitals, post-acute care
facilities, physician groups)
• BPCI hospitals are saving
an average of $1000 over
non-BPCI hospitals
• Key areas resulting in cost
reduction are: standardizing
devices and surgical
preference cards, reducing
readmissions, and
appropriate use of postacute care (PAC)
Current State of National Landscape
2014 Bundled Payment
for Care Improvement
(BPCI)
2016 Comprehensive
Care for Joint
Replacement (CJR)
• Voluntary
• 1st mandatory CMS bundle
(DRGs 469/470)
• 48 potential clinical areas
• Most common bundles:
LEJR, CHF, COPD
• ~1500 participants
(hospitals, post-acute care
facilities, physician groups)
• BPCI hospitals are saving
an average of $1000 over
non-BPCI hospitals
• Key areas resulting in cost
reduction are: standardizing
devices and surgical
preference cards, reducing
readmissions, and
appropriate use of postacute care (PAC)
• 67 MSAs mandated to
participate nationwide (~800
hospitals)
• Now eligible for Advanced
Alternative Payment Model
track of MACRA
• Commercial Payers
engaging in bundled
models (e.g. UHC)
National BPCI Experience
•
158 of the 184 hospitals participating in BPCI selected 90-day episode length
•
Greater decrease in 90-day Medicare payments for lower-extremity joint replacement
patients within BPCI-participating hospitals vs non-participating hospitals (data from 1st 21
months of BPCI initiative)* - see table below
•
Key areas to reduce internal costs are standardizing supply costs, reducing
readmissions, and optimizing the use of post-acute care (PAC)
•
Patient satisfaction has not been negatively affected by BPCI; self-reported functioning
actually improved more for beneficiaries with BPCI LEJR episodes
Mean 90 day Medicare payments for LEJR DRGs
Non-BPCI Hospitals
BPCI Hospitals
Pre-Intervention Period
$30,057
$30,551
Intervention Period
$27,938 (↓$2,119)
$27,265 (↓$3,286)
* Dummit, LA et al. Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes
for Lower Extremity Joint Replacement Episodes. JAMA. 2016, 316:1268.
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2015: BJC (BJH & MBMC) entered BPCI Model 2
Selected to enter BPCI for DRGs 469/470: Major joint replacement or reattachment of
lower extremity (hips, knees, ankles) with/without major complication or comorbidity
Episode of care: 3d PTA to 90d post-D/C
BJC Primary Hip & Knee Volume by Hospital (BPCI Hospitals)
HSO
2015
2016 (annualized)
BJH
1,630
1,552
MBMC
1,162
1,028
Totals
2,792
2,580
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7 BJC hospitals are enrolled in CJR
(too early to have complete data for CJR experience)
DRGs 469/470: Major joint replacement or reattachment of lower extremity (hips, knees,
ankles) with/without major complication or comorbidity
•
BJC hospitals in CJR: AMH, BHC, BJWCH, CH, MHB
•
BJSPH/PWH also in CJR but surgeons in BPCI with different convener
BJC Primary Hip & Knee Volume by Hospital*
HSO
2015
2016 (annualized)
AMH
435
448
BHC
1,297
1,589
BJH
1,630
1,552
BJSPH
315
322
BJWCH
589
638
CH
176
222
MBMC
1,162
1,028
PHC**
85
110
PWH
300
286
MHB
593
696
6,582
6,891
Totals:
*All data from BJC Supply Plus except MHB; data for MHB obtained from MHB surgeon champion*
**PHC is not in a mandated MSA but do have volume in DRGs 469/470
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Current State of National Landscape
2014 Bundled Payment
for Care Improvement
(BPCI)
2016 Comprehensive
Care for Joint
Replacement (CJR)
2017 (AMI/CABG/SHFFT/
Cardiac Rehab Incentive
Model)
• Voluntary
• 1st mandatory CMS bundle
(DRGs 469/470)
• New mandatory bundles to
begin October 1, 2017
• 67 MSAs mandated to
participate nationwide (~800
hospitals)
• AMI mandatory in 98 MSAs
(~1200 HSOs)
• 48 potential clinical areas
• Most common bundles:
LEJR, CHF, COPD
• ~1500 participants
(hospitals, post-acute care
facilities, physician groups)
• BPCI hospitals are saving
an average of $1000 over
non-BPCI hospitals
• Key areas resulting in cost
reduction are: standardizing
devices and surgical
preference cards, reducing
readmissions, and
appropriate use of postacute care (PAC)
• Now eligible for Advanced
Alternative Payment Model
track of MACRA
• Commercial Payers
engaging in bundled
models (e.g. UHC)
• CABG mandatory in 98
MSAs (~1200 HSOs)
• Cardiac Rehab model
mandatory in 90 selected
MSAs
• SHFFT (Surgical Hip and
Femur Fracture Treatment)
mandatory in the 67 CJR
MSAs
90-day cost distributions (2014 Advisory Board [National] Data)
Episode Cost for Percutaneous Coronary Interventions (PCI)
Episode Cost for Acute Myocardial Infarction (AMI)
90 Days After Index Admission
90 Days After Index Admission
Episode Cost Coronary Artery Bypass Graft (CABG)
Episode Cost for Hip & Femur Procedures Except Major Joint (SHFFT)
90 Days After Index Admission
90 Days After Index Admission
BJC EPM Landscape
Cardiac Rehab
(10/17)
prcdr not performed

BPCI LEJR/CJR
SHFFT (10/17)
AMH


BJH


BJSPH


BJWCH


BHC


CH



MBMC



MBSH
prcdr not performed
prcdr not performed
Low volumes
prcdr not performed
 (low vols)
PHC
not in an MSA
not in an MSA
not in an MSA
not in an MSA
not in an MSA
PWH


prcdr not performed

SLCH
n/a
n/a
n/a
n/a
MHB


MHE


Note:  = enrolled in mandatory program
AMI (10/17)
CABG (10/17)
Location

prcdr not performed

Low volumes
prcdr not performed



n/a

prcdr not performed

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BJC Collaborative Landscape
Collaborative
Member
BPCI LEJR/ CJR
SHFFT
BJC
(Stl - 9 hospitals)


BJC (Columbia)




Blessing
(2 hospitals)
not in an MSA
not in an MSA
not in an MSA
not in an MSA
AMI
CABG

Cox Heath
(5 hospitals)
Decatur
Cardiac Rehab
not in an MSA



Memorial Health
System
(4 hospitals)



St. Luke’s Health
System
(8 hospitals)




Sarah Bush
Lincoln
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Southern Illinois
Healthcare
(3 hospitals)
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Micropolitan
Statistical Area
Note:  = enrolled in mandatory program
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System and hospital resources must partner to effectively
develop bundled payment models, including CJR.
System Structure:
Bundled Payment Working Group
(BP WG)
Hospital and Physician Structure:
Hospital-Specific Steering and Working
Groups for Bundles
Chair Person
Operational multidisciplinary group responsible
for coordinating/ advancing BP models across
BJC in partnership with hospitals
Work includes:
 Develop analytics (cost and quality)
dashboards
 Optimize care transitions
 Develop post-acute care network
 Create compliance plans
Multidisciplinary (hospital leadership, surgeons,
other clinical/operational experts, WUSM at
relevant hospitals)
Work includes:
 Develop care protocols
 Develop education
 Implement compliance requirements
 Deploy resources to follow patients over
course of episode
Clinical Expert Councils (CECs)

Multidisciplinary CEC in each bundled area with participation of each relevant hospital
Serve as a system CLINICAL venue for discussion of:
 standardization of care redesign to best practice
 quality metrics
 analytics/dashboard
 other issues
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Bundled Payment Working Group: Members & Roles/Res.
Chair: Dr. Bruce L. Hall
Core Team
Director Clinical Advisory Group
Director, Managed Care
System Bundled Payment Sr.
Project Mgr.
System Team
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
BJC Analytics
BJC Compliance
BJC Finance
BJC IT
BJC Legal
BJC Qual/Reg
BJC Supply
Care Coordination
Accountable Care
Post-Acute Care
Institution Liaisons
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
AMH
BHC
BJH
BJSPH
BJWCH
CH
MBMC
MHB/MHE
PWH
WUSM
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The System Bundled Payment Working Group (BP WG) is
coordinating 6 work streams to support EPMs.
Infrastructure
& Culture
Financial
Readiness
Build strong network of clinical and administrative experts across
BJC/WUSM to coordinate bundles and drive change
1. Use available data to understand current landscape
2. Develop/implement gain share agreements with relevant partners
Health
Information &
Technology
1. Develop comprehensive dashboard (to include efficiency and
quality metrics)
2. Use data to drive longitudinal care redesign
Care
Coordination
& Post-Acute
Care
Understand and optimize:
• Care coordination/transitions throughout longitudinal care episode
• Care at post-acute care facilities
Quality & Care
Redesign
Patient
Centeredness
Understand current state clinical care, clinical experts to partner in
identification of opportunities for improvement/system alignment through
evaluation of data
Maximize capacity to help individuals maintain or return to health by
capturing patient values, preferences, and needs in care plans
Example: Quality & Care Redesign
Following system rapid improvement
event, AMH and CH opened Joint
Wellness Centers to improve education,
patient engagement, pre-op evaluation
for hip/knee replacement patients
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Example: Quality & Care Redesign
Development of standard Risk Stratification algorithm:
 Understand rationale for risk stratifying patients undergoing LEJR procedures
–
–
–
–
Opportunity for optimization prior to surgical intervention
Early identification of risk factors associated with complications, infection, readmission
Early discharge evaluation and planning
Target deployment of resources to follow patients over course of episode
 Review literature and current practices within BJC
– Discussion of current state and opportunities for standardization
Next Steps:
• With surgeon and multidisciplinary
participation, develop standardized risk
stratification algorithm to pilot
Example: Care Coordination & Post-Acute Care
BHC and MHB have each
approved additional FTEs
as “care navigators” for
their hip/knee replacement
population
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Example: BJC Cardiac Bundle Work Underway
Process mapping to understand variation in patient flow and protocols across BJC landscape
Crosswalk of registries and metrics tracked at each HSO
Development of comprehensive stakeholder list for each HSO
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Next Steps
Critical areas of focus in 2017 include:
1. Building out analytics scorecard (to include post-acute care metrics)
2. Aligning with additional Care Coordination efforts taking place within the
system
3. Continuing to strengthen relationships with post-acute care partners
4. Working with our Clinical Expert Council partners who will redesign the way
care is delivered along the 90-day continuum
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“Value Based Care” is here to stay. Despite legislative uncertainty,
the concept of value based care will continue to be a focus into 2017
and beyond.
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What To Do
• Improve your game
• Leverage technology
• Develop tools, techniques, competencies
• No longer Monday – Friday; varsity players and shifts
• Invest in clinical knowledge, NPs, SNFs, etc.
• Understand protocols
• Communicate, communicate, communicate
• Measure and report
• Keep your stars up
• Focus on outcomes at the least cost = value
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Changing Landscape of Long-Term
Care: Hospital Partnerships
Dan Rothery
President, BJC Home Care and Community Services
VOYCE Conference
June 8, 2017