A hands-on approaches for hospitals to strategically align orthopedic surgeons and post-acute providers under CJR. This Presentation focuses on tools that providers can use to help manage their performance to be successful under the new value-based environment.

1. February 24, 2016
Demonstrating
Who You Are
in CJR:
Data Describes the
Problem,
Providers Deliver the
Solution

2. © QURE 2016
Agenda
• Introduction
• CJR review
• Cost management strategies
• Defining CJR success
• Q&A
2
Jay Sultan,
Edifecs
Principal Strategy
Advisor
John Peabody,
MD, PhD, FACP
President,
QURE
Healthcare
Professor, UCSF,
UCLA
Speakers

3. © QURE 2016
CJR Highlights
• No choice about participation
• Focus on post-acute care
• Risk is borne by hospitals
• New opportunities for improving
care
• Mandate to lower total episode
costs
• Episode impact will not be
limited to CJR
3
Critical implications for hospitals

4. © QURE 2016
Are Hospitals Prepared for CJR?
4
39%
have no experience of
managing LEJR episodes
43%
just getting started with
bundled payments
44%
in planning stages to analyse
historical data to identify best-
performing PAC providers
30%
do not know if they will
enter into gainsharing
with SNFs
30%
rely on manual ways to
administer gainsharing
payment
52%
limited data sharing
experience with providers
5Top-most challenges faced by providers
Tight timelines to
prepare
Gainsharing program
administration
Ongoing episode
monitoring & reporting
Partnership
agreements/contracts
with providers
Care redesign for
the entire episode
Source: CJR Readiness survey conducted by Edifecs, February, 2016.

5. © QURE 2016
CCJR And High Variability in Clinical
Practice Costs
Select MSA Wage-Adjusted Episode Payments for TKA in CMS’ 9 Target Price Regions
• Higher: $32, 060
• Las Vegas-
Henderson-
Paradise, NV
• Lower: $21,1660
• Lake Havasu
City-Kingman, AZ
• Higher: $28, 219
• Los Angeles-
Long Beach-
Anaheim, CA
• Lower: $18,440
• Napa, CA
• Higher: $25,780
• Norwich-New
London, CT
• Lower: $24,200
• Portland-South
Portland
• Higher: $33,072
• Miami-Fort Lauderdale-West
Palm Beach, FL
• Lower: $24,472
• Myrtle Beach-Conway-North
Myrtle Beach, SC-NC
• Higher: $31,076
• New York-Newark-
Jersey City, NY-NJ-PA
• Lower: $25,091
• Albany-Schenectady-
Troy, NY
• Higher: $32,544
• Beaumont-Port Arthur, TX
• Lower: $26,123
• College Station-Bryan, TX
• Higher: $31,789
• Tuscaloosa, AL
• Lower: $26,312
• Evansville, IN KY
• Higher: $31,198
• Carbondale-Marion, IL
• Lower: $23,052
• Davenport-Moline-Rock
Island, IL
• Higher:$25,664
• Springfield, MO
• Lower: $21,469
• Iowa City, IA
Sources: Centers for Medicare and Medicaid Services
5

6. © QURE 2016
Variation in Discharge Patterns
Hip/Knee replacement
facts
• Cost of post acute care
growing 15%/year and
is now greater than cost
of actual surgery
• 300% variation in
nursing home utilization
• Discharge patterns vary
enormously by regions
within states
6
Sources: Definitive Healthcare, 2013 Medicare SAF (1/1/2013 – 12/31/2013)
Note: # for every 10 patients rounded to the nearest whole number

7. © QURE 2016
Managing Two Cost Structures
7
Managing Hospital’s Own
Cost
• With or without CJR, all hospitals
need to manage this
• Focus is on LOS, implantable costs,
formulary, readmission
• Hard for most hospitals to do more
without physician’s cooperation
Managing CMS’s Cost
• Within the gainloss and gainshare, the
hospital earns or loses 100% of
CMS’s spend during the post-acute
period
• Other providers are spending your
money
• A single patient who is discharged
home instead of a SNF could mean
thousands of dollars in gained
revenue.

8. © QURE 2016
Equip Leadership with Analysis of Historical Data
to Design the CJR Program
8
• Intake and validate
historical CMS episode
payment data
• Perform episode volume
analysis by DRG, LEJR
procedure, comparison
with regional episode costs
• Perform trended and
annual inpatient and post-
acute provider utilization
and cost analysis
• Assess quality outcomes
and isolate factors driving
quality variations
Source: Edifecs

9. © QURE 2016
Key Considerations for Cost Management, All Start
with Better Care
Pre-Admission (surgeon’s office)
Better screening and management of conditions prior to admission, to reduce
LOS and complications
Better patient engagement (and education) pre-admission, to set expectations
on pain and other topics and to start discharge planning with a presumption on
home discharge when possible
During Acute Care (hospital and physicians)
Better management of all costs related to implantable vendor choice
Better coordination between anesthesia and surgeon (reduction of
unwarranted variation, better pain management)
Better engagement of physician in managing post acute (what they can do
before or at time of discharge, what they can do post discharge)
9

10. © QURE 2016
Implementation
The Clock Is Ticking…Hospitals Have < 2 Years to
Align their Providers Before Penalties Begin
10
Apr. 1: First Performance
Period Begins
2015 2016 2017 2018 2019 2020 2021 2022
Design
Year 2:
• 5% stop loss limit
• Target Price: 2/3 hospital, 1/3 regional
Year 4 & 5:
• 20% stop loss limit
• Target Price: 100% regional
Year 3:
• 10% stop loss limit
• Target Price: 1/3 hospital, 2/3 regional
Year 1:
No payment
responsibility
Nov 16: Final Rule Posted – Hospital Controls
Jul 9: proposed framework in Federal Registrar
July 9 - Sep 8: Comment Period – Proposal for Physician
Control of Bundle
Sources: Centers for Medicare and Medicaid Services

11. © QURE 2016
The Paradox for Hospitals
You Control the Bundled Payment but Docs Control the Spending
• Clinicians lost control of the funds
flow but they still have the most
control over clinical care
• Hospitals are responsible for
episode costs that are decided by
clinicians
– Inappropriate, non standardized
care, and/or complications drive
up costs
• Hospital leadership is limited in the
ways they can engage clinicians on
changing clinical practice
Hospital-Clinician Alignment
will be Critical to Success
11
Clinical Independence
Financial Risk
Source: QURE Healthcare

12. © QURE 2016
Home HealthAnchor
Hospitalization
Physician Fee
Schedules SNF LTCH - IRF
Readmissions
CJR Episode Bundle, MS-DRG 469, 470
Outpatient PT
Episode EndsEpisode Trigger
90 Days
You Are Now the Payer…
…and Consumers Will Choose
1. Costs are going (way) up for patients
2. Consumerism is here
Choosing based on cost instead of quality?
3. Quality is its own reward
Voluntary Patient Reported Outcomes (PROs) can result in an additional 10%
contribution to your composite quality metric score
Quality and care standardization reduce your costs
PROs!!
Sources: Centers for Medicare and Medicaid Services , Edifecs
5

13. © QURE 2016
Key Recommendations
To Successfully Engage Providers in the CJR
13
Align Around Efficient Practices
Develop standardized care pathways that incorporate
evidence-based guidance and local physician expertise
Target Unnecessary Variation
Identify target areas to focus group-level care that
will have a significant impact on cost AND quality
Gauge and Engage Providers
Use tools that facilitate physician
engagement, cost and quality measurement
Arm Leadership with Resources and
Data on Value
Closely align with physician leaders to ensure Value =
Quality ÷ Cost
2
4
3
1
Increase Value while
Reducing CostsSource: QURE Healthcare

14. © QURE 2016
Lower Extremity Joint Replacement,
Several Expert Consensus Clinical Guides Are Needed
14
Source: respective organization websites

15. © QURE 2016
4.3
4.3
4.3
6.5
45.7
0 10 20 30 40 50
Infetion and inflammatory reaction
due to other internal orthopedic
device, internal fixation device
Other mechanical complication of
prosthetic Joint
Dislocation of prosthetic joint
Osteoarthrosis, localized second
knee
Infection and inflammatry reaction
due to internal joint prosthesis
Why We Need to Get Care Right:
Infections and Prosthetic Complications Drive Surgical Revisions
15
< 3 months 3-6 months 6-12 months >1 year
Total Number 151 32 30 9
Percentage 68% 14% 14% 4%
American Joint Replacement Registry: Time between Primary Hip and Knee Procedures Performed in
2012-2013 (n=222)
7.3
8.5
14.6
31.7
37.8
0 10 20 30 40 50
Mechanical loosening of prosthetic
joint
Other mechanical complication of
prosthetic joint implant
Dislocation of prosthetic joint
Peri-prosthetic fracture around
prosthetic joint
Infection and inflammatry reaction
due to internal joint prosthesis
Top 5 TKA Revision ICD-9’s (%) Top 5 THA Revision ICD-9’s (%)
Sources: American Joint Replacement Registry. The American Joint Replacement Registry Annual Report 2011.

16. © QURE 2016
Alignment Means
Adoption of Evidence-Based Care to Drive Quality and Value
Standardized Care Protocols:
Outline most appropriate clinical path for patient types
Care path begins with pre-op planning and evaluation through the
procedure to the post-hospital stay
Post-operative costs are determined by preoperative evaluation and
hospital stay
16
CJR represents an opportunity to introduce and emphasize
Evidence-Based Care
Source: QURE Healthcare

17. © QURE 2016
Why We Need to Get Care Right:
Initial Care has a Cascading Effect
17
• History
• Cardiac Assessment
• Physical Assessment
• Radiological Exams
• Treatment Referral
SNF LTCH - IRF
Outpatient PT
Home Health
$$$
$$
$
Re-admissions
Patient Reported
Outcomes
• Anesthesia
Selection
Pre-Operative Operation PACU/Recovery Post-Operative
• Procedure
Selection
• Implant Selection
• Prophylactic Care
• Wound Management
• VTE
• Physical Therapy
• Early Mobility
• NutritionSource: QURE Healthcare

18. © QURE 2016
Watch
Recorded webinar
Demonstrating Who
you Are in CJR
Questions? Contact us
Courtney.tory@edifecs.com
425-434-2200
Join US
Upcoming Webinars
Download
Presentation
in Full

19. © QURE 2016
Too Much Variation:
The Need to Standardize the History and Physical Examination
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• Patient history includes onset and duration of symptoms, location and severity of pain, activity
limitations (e.g., walking distance, use of assistive devices, and difficulty with stairs)
• Physical examination includes gait, knee range of motion, presence or absence of deformity of
the knee, stability of the knee, neurologic status (sensory and motor function), vascular status
(peripheral pulses), skin, height, and weight
Review of 224 TKR patients in 3 affiliated hospitals
• Present illness documented in 54% of patients
• Pain evaluation documented in 60% of patients
• All components of the physical examination documented in 5% of patients
• Identifies medical problems that need to be corrected prior to the procedure
• Pre-operative activity level and symptoms helps determine the severity of knee arthritis and
baseline functionality
• Necessary to plan for the surgical procedure
2003
Consensus
Guidance
Real-Life
Practice
Clinical
Importance
Sources: American Joint Replacement Registry, Annual Report 2015 ; American Association of Hip and Knee Surgeons, Total Knee Replacement, Performance Measure Set, Jan.
2013SooHoo N, Tang E, Krenek L, et al. Variations in the quality of care delivered to patients undergoing total knee replacement at 3 affiliated hospitals. Orthopedics 34(5):356,
2011.; American Academy of Orthopaedic Surgeons. AAOS treatment guideline of osteoarthritis of the knee full guideline. 2008.
2013