On April 1, implementation of the CMS expanded Bundled Payments for Care Improvement demonstration for hip and knee replacement (aka CCJR) begins. This phase takes the initial voluntary BPCI program and expands the concept on a non-voluntary basis to 67 metropolitan regions. See my post on the final rule here at http://wp.me/ptUlY-jh. Effectively, Medicare reimbursed knee and hip joint replacements through a covered (Medicare) center (hospital or qualifying surgery center) within one of the designated regions, will be paid on a “bundled” basis.
Overview
Beginning April 1, 2016 (and for five consecutive years) CMS will establish a target price for each designated region for each episode (hip or knee) of care. This target price is then discounted by 2% and operates as a benchmark – the bundled payment amount. For any Medicare hip or knee replacement surgery at the qualifying hospital, the payment is designed to reflect the costs of the admission, surgery, hospital services, and all additional post-acute costs of care for 90 days following the surgery. All providers, including the hospital and suppliers, bill Medicare for care provided (Parts A and B as applicable) on a fee-for-service basis. CMS then aggregates the payments made via Medicare for the referenced element of care and all other related (hip and knee) elements across a performance year and compares the same to the regional target. If costs incurred are equal to or lower than the target (bundled payment benchmark) and the hospital met or exceeded certain quality measures, a bonus or reconciliation payment is made (payment is the difference between the actual costs and the benchmark, up to a specified cap) to the hospital. In year one, no penalty is applied for costs above the benchmark or lesser levels of quality. In year two however, less than targeted cost or quality outcomes will create a payment recoup scenario equal to the cost difference compared to the benchmark, up to a certain cap.
Implications for SNFs
For SNFs, while there is no direct correlation in Medicare payments per the bundled payment initiative (no bonus applicability, penalty, etc.), the indirect implications are enormous and potentially for many, survival (or not) deep. Consider the following;
- While the hospital is accountable directly for costs and quality, the cost benchmark covers all care costs within the element of care, including the SNF post-acute stay. An expensive, inefficient stay imputes higher costs into the “total cost” equation.
- While the hospital is directly accountable for the quality measures, the quality measures cross domains. Poor quality, readmissions, low patient satisfaction affects the over quality measures and can lead to payment reductions after year one. The quality measures are;
- Complication rates post procedure
- Readmissions within 30 days
- Patient satisfaction of providers across the element of care
- After year one, only SNFs (that) rated three stars or above can participate in the program. Hospitals can only refer to 3 star or higher ranked providers.
Taking into account the three points above, SNFs can and will experience, game changing referral and relationship dynamics within the affected regions. Hospitals will seek (and have sought) relationships with high quality, cost-effective post-acute providers. For example, one hospital system that I advise regularly has drawn a clear line for referrals at 4 stars and preferably, 5 stars – one year ahead of the requirement. They have already shifted their referral practices in anticipation. Further, as the Final Rule created opportunities (regulatory laxity) and freedom for incentive sharing, alliances are forming whereby providers will share incentives in order to assure high quality, cost-effective outcomes.
Strategies for SNFs in a Bundled Payment Region
While April 1 looms, there is still time for an SNF to get properly positioned initially, for a bundled payment transition. Why I say initially is that most providers, including hospitals, will not be fully ready (and CMS is still providing additional details) for the “new” reality. As with all programs of this nature, a great deal is learned as lived as regulatory details dribble past deadlines and frankly, many providers simply won’t have systems in-place, fully integrated to monitor the costs, quality measures, etc. across all domains. Further, year two is where the game really changes as penalties apply in addition to bonus opportunities and the three star limit becomes effective.
Below is my outline or roadmap that SNFs should follow to succeed and thrive in a bundled payment environment. Note: CMS will push forward, additional elements of care, beyond hips and knees, with bundled payments. Likewise, regions will expand and targeted regulations (separate from bundled payments) for SNFs impute quality measure impacts on payments (commencing in October 2016). Simply stated: the following has broader implications than just bundled payment implications.
- Manage Your Stars: Simple but difficult for many. If your facility is not four stars or above, you will have trouble and will see a reduction in Medicare census and referrals. Even three stars is and will be, inadequate. This is especially true in a market where there are competing facilities at the three or better (star) level. Changing your star rating is not an overnight process but the best start is to drill hard on your quality measures (improve) and survey results. Staffing numbers can shift quickly but only by integrating more professional nurses at the bed side, without reductions in per patient day staff ratios (a financial investment). Remember, with PBJ forthcoming, the numbers can’t be “phantom” staff (sorry but too many SNFs today have jacked up their star levels by gaming the self-reported staffing system).
- QA Your Care Transitions: No SNF should today, fail to intimately manage their care transitions – all transitions. Readmissions are a risk area in bundled payments and today, for SNFs regardless (readmission penalties apply for 2016). Similarly, one of the simplest ways to manage costs related to any stay is to insure that the maximum level of care is available on-site and the resident doesn’t need to transition for things like wound management, radiology, other diagnostics, physician visits, etc. The cost of the transport if attended and billable, the costs associated with the encounter, the diagnostic, etc. all “count” in the analysis of the cost of care per element against the bundled benchmark. In addition, risk is inherent in any transition for a resident/patient. Everything from infection to fall risk heightens when a resident/patient is transported out of the environment and then back.
- Excel at Advanced Care Planning and Discharge Planning: From the hospital encounter through the SNF stay and beyond, keeping the stay efficient and the resident/patient satisfied is all about care planning and discharge planning. The rule of thumb is the earlier the better. If possible, assign a Care Coordinator to the encounter, early – ideally concurrent with the hospital admission. Discuss the options with family, the patient, the team and build as much into the discharge plan as early as possible. For example, if “home” is the goal, get into the patient’s home as early as permissible. If there is family involved, start teaching and providing resources as soon as possible. If post SNF care is required, connect as much of it (e.g., home health) as early as possible and get the other provider elements into the equation ASAP.
- Use an Algorithm or Pathway: Build a hip and knee protocol, pathway/algorithm that covers all elements (typical) of therapy by day by type of surgery. Inclusive should include radiology protocols, pain, wound care, supplies, safety precautions, etc. Work this protocol through your QAPI process with your physicians/Medical Director. Ideally, get hospital folks to react and help and add input, especially Orthopods (if they will participate). I recommend incorporation of pharmacy, nutrition, nursing, and social service as integral elements, especially as the same relate to co-morbidities or post-surgical management. For example, having pharmacy manage and coordinate your anti-coagulation protocol. The more you can develop a “recipe” for folks to follow and measure, the greater the likelihood of a smooth transition, exceptional outcomes, and enhanced patient satisfaction.
- Manage and Align Your Partners: Understanding that risk comes from multiple elements is key to achieving high quality and superior efficiency. Many SNFs use contractors for care elements such as therapy and pharmacy, physician services, etc. Every discipline that is part of the care process must be aligned to assure high quality and efficient care. This environment (bundling) is different now. Its not about “more” care as many have become accustomed via Medicare RUG maximization and extending lengths of stay. It is about the right care. Physicians need to help; keep orders simple, reduced redundancy and unnecessary tests, etc. Pharmacy needs to do medication reconciliation at admission and actually, somewhat virtually. Formularies must be tight to assure the most targeted, effective, and lowest cost medication regime. If home health is part of the discharge process, pick a single partner or limited partners and integrate them into the process. Remember, the risk areas encompass satisfaction and cost elements across a 90 day horizon!
- Build Your Core Competency: Delivering high quality, cost-effective care is about having exceptionally competent, well-trained staff giving the care, supported by focused, competent management. Nurses must be capable of caring for the patient profile from wound to pain to skin to all other components. All staff must be responsive and focused on issues like fall risk, weight loss, dehydration, infection, etc. These issues are monitored daily and part of, what should be, an integrated QAPI program. Social Workers must be able to field questions, coordinate resources, and be responsive, informative and knowledgeable about resource issues (Medicare, insurances, etc.). Review all aspects of care and look to bring them into the environment if feasible. For example, invest in anti-coagulation machines, products to float heels (Heelzup), proper size wheelchairs, patient lifts, air mattresses, etc. I commonly recommend having at least some staff wound care certified, pain management certified, cardiac certified, etc. I like to have therapists with advanced training in neuro, lymphedema care, sports medicine (great for ortho rehab), etc. Without the resources in-house, it is very unlikely that an SNF will be able to manage the current and go-forward demands of lower cost and higher quality.