Episode of Care Tenncare It Has to Be About the Patient Robert Ripley MD Jan 22 2018 Introduction to Tenncare Episode of Care Program This is a synopsis of standardized features of the Tenncare Program for "75 Episodes of Care". The objective of this program is to improve the health and lower the health care costs for the citizens of the State of Tennessee. The objective of reducing the rate of growth of Tenncare costs has been achieved. This program is part of the CMS Innovation Initiative within the general plan for alternative payment programs. As a local State program, Tenncare under the leadership of The Medical Director Dr. Vaughn Frigon, with the assistance of the McKinsey consulting team, has demonstrated exemplary success and is a model for other Medicaid programs. The secret of their success has been careful physician engagement in episode details, due to given the design of the State of Tennessee's program, and transparency of information. Given the success of the episodes program, the question arises of what can be done next? Perusing the details below may provide some ideas. The opportunity to influence CMS alternative payment programs could arise from understanding the uniqueness of the Tennessee version of the episode program. These features are elegantly simple yet collectively could be assembled into a plan or structure that applies to any version of alternative payment programs. What may be more effective in cost containment, is to make available this assembly for purposes of promoting care coordination and collaboration which indirectly must be the foundation for cost containment. The uniqueness of the Tenncare episode program lies in its performance as an exemplar of collaboration. The structure of the design with the details of the clinically based episode is presented to panels of physicians called Technical Advisory Groups or TAGs. The juxtaposition of the episode structure with the codes of the clinical details generated generate extensive back and forth discussions. No other process such as this exists in other value based purchasing programs at the CMS level. This shows the advantage of a State based program that interacts closely with local physicians. This process when facilitated by the skilled coordination of Dr. Frigon allows the program to reflect careful and sincere emphasis on real world clinical processes. The best realization of managed care or population health, must come from this input from those engaged on a daily basis in care delivery. From a patient centered physician point of view, the process of reviewing the detailed codes of the episode features resembles a CPC (clinical pathologic conference) which is the mainstay of the clinical learning process. Review of the episode features show how they may be a basis of linking population health to care performance and redesign. Tenncare Episode of Care Program Features Episode base definitions: Episode triggers Attributing episodes to quarterbacks Identify services to include in episodes Risk adjusting and excluding episodes Determining quality metrics performance Patient journey for episode: Presentation Initial evaluation and stabilization Continued evaluation and management Follow up care Potential complications Sources of Value for work up: Presentation to appropriate site of care Appropriate determination of differential diagnoses Avoidance of unnecessary diagnostic testing Appropriate choice of diagnostic testing when indicated Appropriate site of care for continued care Appropriate treatment(s) to address the underlying cause (of trigger) Patient education and counseling to prevent repeat events Appropriate follow up care - additional treatment monitoring response to response to treatment Prevention of complications Restoration of functionality Five important areas of episode design: Identify episode triggers Attributing episodes to quarterbacks Identifying services to include in episode spend Risk adjusting and excluding episodes Determining quality metrics performance Trigger Group conditions, reliance on physician engagement: Primary triggers Contingent triggers Considering for selecting a quarterback Decision making responsibilities Influence over other providers Distributions of average non risk adjusted episode spend across quarterbacks in Tenncare Identifying services to include in episode spend: Features... Tme window up to 30 days Types of services... Risk adjusting and excluding episodes Inherently more costly factors Non comparable are excluded Business exclusions, clinical exclusions for effect on clinical pathways, high cost outliers Risk adjustment model on historical data to identify what factors drive episode spend in a population, factors not preventable are used to exclude episodes, preventable factors are not risk adjusted, factors may identify a different patient journey, physician input to determine the above Quality Metrics tied to gain sharing vs. information only Link to gain sharing, ensure no provider receives gain sharing for lowering cost by compromising on quality Information only quality metrics emphasize and highlight some known challenges to the State Quality metrics based on claims vs. other information sources Design and launch 75 episodes and an extensive patient centered medical home program Enhance the ability to measure and reward good quality through sources other than medical claims. These comprehensive features of the episodes support cost benchmarks applied to quarterbacks. It is clear these features need not be limited to this objective. Consider other uses of these features, particularly if the assembly of the features can be modular. Taking a look at the features each considered in isolation, can show how they may work to support care redesign as an extension of the comprehensive episode design based on claims and other information sources. Strengths of Tenncare Episode program: From fundamentals of design features Physician engagement: Program design of features listed above initiates the physician engagement using the form of a roundtable discussion. Topics start with the design features, and each topic is extended into a broader and deeper space of meaning and relevance of codes. This space includes the complex context of clinical care which includes precision of diagnosis, pathophysiology and biology, social and psychological dimensions, and provider network management of patient journeys. It is no surprise to physicians that clinical care requires an awareness of the high dimensionality of information when context is included surrounding the care event, from the trigger to the resolution of the journey. The roundtable discussion will amplify the code based features of the episode design, and though the context is not always relevant to the purpose of accountability for the episode cost, at least the context is engaged. For example many episodes may not fit into the time intervals specified by episode design, particularly for chronic conditions. Because this insight is recurrent in the roundtable discussion of many episodes, there is a sense future episodes programs will reflect this common comment. Another example is the quarterback concept as the provider or institution that has the greatest ability to influence cost of an episode. For most episodes which require a transition of care, such as referral to a specialist or ER visit as an event in chronic care, there is no single entity that can be reasonably assigned accountability. Physicians see themselves as participants in a network environment of providers, and groups of providers as collectives influence care decisions. For complex episodes particularly when a trigger occurs in the context of chronic disease, this network is in play. The program design is to limit the cost of the journey to the trigger, and treat the other disease entities as risk variables. The issue here is that the manager of the chronic condition is more likely to determine episode cost than the quarterback of the episode . Physician engagement raises the issue of coordination and collaboration, provider crosstalk, within the network collective. Here pre trigger transitions of care are deemed important These general comments above can be applied to the specifics of the episode features. Sources of Value for work up, how to benefit from engaged physician? Presentation to appropriate site of care Transition Network Appropriate determination of differential diagnoses Provider centric Collaboration standards Avoidance of unnecessary diagnostic testing Transparency Counterfactual technology Dependent on access to data source Appropriate choice of diagnostic testing when indicated As above Selection of tests function of what? Standards Appropriate site of care for continued care Similar to bundles Avoid chronic care Appropriate treatment(s) to address the underlying cause (of trigger) Pathophysiology Standards Patient education and counseling to prevent repeat events — Transitional care Appropriate follow up care, additional treatment monitoring response to response to treatment — Transitional care Prevention of complications — Upstream influence pre trigger Restoration of functionality — Transitional care Patient journey for episode, how to benefit from an engaged physician? Presentation Same or similar to trigger Site of presentation important Initial evaluation and stabilization Provider centric Collaboration Coordination Direction for transitions Continued evaluation and management Assemble groups of codes Reflected in collective of network How does network function within the time limits of an episode? Follow up care — Use model of Transitional Care Management (TCM) ; collect all services for the patient collected by a single provider of record. Make network aware this is a reimbursable service. Potential complications — Part of risk stratification Risk adjusting and excluding episodes, how to benefit from an engaged physician? Inherently more costly factors. What are these factors? Non comparable are excluded Business exclusions, clinical exclusions for effect on clinical pathways, high cost outliers Risk adjustment model on historical data to identify what factors drive episode spend in a population, factors not preventable are used to exclude episodes, preventable factors are not risk adjusted, factors may identify a different patient journey, physician input to determine the above. Large issue, what are the factors? Risk adjustment based on codes done on a population limited to the plan. Is there an opportunity for holism where patient specific factors are classified by broad context? Transparency: Path to influence Risk stratification for fair comparison Cost of episode From episode fundamentals to broader impact on Tenncare spend Source of variation of spend transparent to network collective. Define units of measurement from scale free network. Locate best source of influence on spend, identify most linked provider or collective in the network. From Broad Impact on Tenncare Spend to Impact on all Payment Models. Founded on broad impact on Tenncare through physician engagement and transparency, features of the episode technology can be extended to the range of payment methods of all types used by Tennessee physicians. This quite simply is showing the episode feature are the same for all programs from MIPS for fee for service payment, bundled programs, accountable organizations such as Patient Centered Medical Homes, and accountable care organizations. This use of episode features for all these programs is possible because the Tenncare has shown the key in health care reform. With engagement and transparency applied to episode features, not just the episode program as a whole, health insurance reform becomes one and the same with health care delivery reform. Contrast engagement and transparency in the Tenncare context with the quality benchmarks HEDIS, and STAR system programs of commercial insurers. Here compliance is prespecified with a small number of outcomes only relevant for primary care. True reform requires change in many dimensions, known and unknown to each provider type, but known collectively when the audience for health delivery change is the network. This in effect is scaling up from patient centered data, to a holistic view of the patient, which can be transparent to the entire network, and thus to the population scale. Being holistic the patient and population scale merge to include diverse drivers of costs, including environmental, psychosocial, disease effects on patient's health status. It is quite easy to imagine that episode features can be used to profile and benchmark collectives such as networks as well as the episode program applied to quarterbacks. This is how the Tenncare program can jump ahead of the pack to show a model of health care reform that from a data standpoint is high dimensional, from accountable care standpoint satisfies many programs, from a providers standpoint creates a model of common standards spanning all plans, and from a risk stratification and cost effectiveness standpoint creates a learning environment for health care transformation.