Medicare Shared Savings Program

Orlando Health Collaborative Care

Multidisciplinary relationships formed between primary care providers and their specialist and facility counterparts engenders a patient-centric, quality-conscious healthcare ecosystem. Through these partnerships, and with the use of sophisticated reporting and analytics, providers across the care continuum collaborate to reduce waste through the implementation of cost-effective processes and care plans. The result of these efforts is a bettered patient care journey that both reduces out-of-pocket cost to the patient and saves taxpayer money.

Orlando Health has participated in MSSP through its own ACO, Orlando Health Collaborative Care (OHCC), since 2013. Today, OHCC is engaged in the most advanced version of the program, known as the Enhanced ACO track, which compares performance to nationally and regionally determined benchmarks for cost and quality. Based on its 2021 performance which was heavily impacted by effects of the pandemic, OHCC was able to maintain cost performance within one percent of its benchmark goals while generating the significant quality results shown on the following page. This marks the ninth straight year of performance in the program and positions OHCC to provide continued outstanding care to its aligned Medicare beneficiary population for years to come.

For information on current performance, please visit our site here: Orlando Health Collaborative Care.

Bundled Payments for Care Improvement – Advanced (BPCI-A)

Orlando Health has participated in the Centers for Medicare & Medicaid Service’s (CMS) voluntary Bundled Payments for Care Improvement – Advanced (BPCI-A) program since January 2020. Participation in the program requires the health system to manage patient journeys through entire clinical episodes of care, beginning at the time of an inpatient admission until 90 days after the initial hospitalization. Orlando Health is at significant financial risk in this program as it is responsible for all care rendered to the patient during the entire clinical episode, including with healthcare providers and at sites of care not owned or operated by the health system.

If Orlando Health can effectively collaborate with all inpatient and outpatient care providers to provide quality care throughout the patient’s healthcare journey while effectively managing total expenditures, it can earn an incentive payment. However, if costs are not well managed and exceed the determined target prices set by CMS, Orlando Health will owe a penalty payment.

In 2022, Orlando Health participated in 12 clinical episodes across three services lines, as shown below

Orlando Health’s 2022 Clinical Episodes 

Gastrointestinal Care

• Gastrointestinal Obstruction
• Gastrointestinal Hemorrhage
• Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis
• Inflammatory Bowel Disease

Medical and Critical Care

• Sepsis
• Simple Pneumonia and Respiratory Infections
• Chronic Obstructive Pulmonary Disease, Bronchitis, Asthma
• Renal Failure
• Urinary Tract Infection
• Cellulitis

Neurological Care

• Stroke
• Seizures

Through its current BPCI-A participation, and harkening back to success in the original Bundled Payments for Care Improvement program spanning from July 2015 to October 2018, OHN has implemented a variety of clinical care initiatives to address education and performance improvement in the program, including:

Bundled Operational Leadership Team (BOLT) Meetings: Multidisciplinary teams, composed of subject matter experts and executive leaders at each hospital facility, participate in quarterly BOLT meetings to review performance and outcomes data, identify key metric trends and opportunities for improvement in the program, and implement initiatives and interventions with the teams.

Care Management Meetings: Operational teams meet with the inpatient care management managers at each facility monthly to discuss program performance trends and perform patient level reviews to address next site of care (NSOC) utilization and preventable readmissions.

Care Management BPCI-A Education: Management teams present information to care coordination staff at each participating hospital site to review current program guidelines, provide decision-making tools and lessons learned, and discuss care coordination best practices for post-acute navigation.

Acute Care Therapy BPCI-A Education: Management teams present information to therapy teams at each hospital site to introduce program concepts, offer NSOC decision-making recommendations and elucidate the role of therapy in discharge planning via interdisciplinary team discussion.

Inpatient Rehabilitation Education: Monthly interdisciplinary meetings are conducted with the inpatient rehabilitation leadership team to review patient cases in which such services were utilized, identify care redesign opportunities and analyze facility outcomes (e.g., 30-day hospital readmission rate, length of stay, average spend, NSOC referrals, etc.).

Post-Acute Care Network Clinical Pathways: Hospital transitions and value-based care teams working with the Orlando Health high-value post-acute care (P-AC) network implement evidence-based clinical tools designed to support post-acute partners in caring for patients enrolled in a BPCI-A episode of care by specifically focusing on appropriate length of stay, avoidable emergency room visits and hospital readmissions.

Post-Acute Readmission Reviews: Quality care teams conduct patient-level hospital readmission reviews alongside P-AC network partners to critically evaluate all aspects of care, from pre-admission to the acute hospitalization to the transition of care. Identified gaps in hand off from the hospital to the post-acute care partner are then remedied to prevent future avoidable readmissions.

Comprehensive Care for Joint Replacement (CJR)

In 2018, the Centers for Medicare & Medicaid Services (CMS) mandated that certain inpatient facilities, including Orlando Health, partake in the Comprehensive Care for Joint Replacement (CJR) bundled payment program. This program is focused on reducing overall spend by increasing care coordination and improving the quality of care that is provided to patients receiving major joint replacement surgeries, including knee, hip and ankle replacements. The health system is at economic risk in this program and therefore may incur financial penalties if patients have total costs of care exceeding expected thresholds, often driven by hospital readmissions and/or extended lengths of stay within post-acute settings.

Orlando Health is responsible for managing patients in this episode-based program across four Medicare Severity Diagnosis Related Groupings (MS-DRGs), including:

• MS-DRG 469 - Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with Major Complications or Comorbidities (MCC)
• MS-DRG 470 - Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC
• MS-DRG 521 - Hip Replacement with Principal Diagnosis of Hip Fracture with MCC
• MS-DRG 522 - Hip Replacement with Principal Diagnosis of Hip Fracture without MCC

During Plan Year 2022, Orlando Health Network (OHN) has worked in collaboration with hospital leaders across the health system to communicate the importance of this program and to identify opportunities for improvement. OHN has leveraged three major tools to better program performance: (1) collaborative multidisciplinary meetings, (2) patient case reviews, and (3) systemwide care redesign initiatives.

Collaborative Multidisciplinary Meetings

Meetings are held regularly at each hospital campus to provide program education and actionable takeaways to drive performance improvement. These meetings include representation from hospital senior leadership, orthopedic surgeons, surgery administration, infectious disease experts, rehabilitation teams, care management, quality improvement, practice managers, nursing, and post-acute facility leadership.

Bundled Operational Leadership Teams: Facility-level performance teams engage in program data and metrics reviews to create and discuss focused performance improvement efforts within the hospital.

Corporate Collaborative Joint Meetings: Hospital leaders across the health system meet to discuss collective program performance, review opportunities for improvement and share best practices seen at the respective hospital sites.

Working Group Sessions: A dedicated workgroup for Orlando Health Orlando Regional Medical Center convenes with front-line orthopedic team members to discuss both short-term and long-term strategies for clinical and administrative changes. The team also conducts brainstorming sessions to create new models of care and share findings from literature review to be piloted. Program results are reviewed to assess if processes and protocols should be expanded across the health system broadly.

Orthopedic Service Line Meetings: Orlando Health Jewett Orthopedic Institute surgeons and affiliated surgeons review the latest clinical research findings and suggest program updates to be implemented across the orthopedic service line.

Post-Acute Site Meetings: Weekly touchpoints are held between OHN care coordination resources and post-acute facilities caring for CJR patients to ensure appropriate length of stay targets are achieved and that patients have access to necessary resources post-discharge.

Patient Case Reviews

Individual chart reviews are performed by the OHN medical director and management teams overseeing advance practice provider operations, hospital coding, billing and support specialists, and inpatient care coordination.

Patient Journey: Individualized patient journey maps are created to capture all clinical care interactions a patient may experience from the time they elect to have surgery through the end of their 90-day episode. This process serves to set expectations for the patients and their families, while also enabling operational teams to adequately prepare for specific patient needs.

Surgical Case Reviews: Once a surgery has been scheduled, patients are closely followed by a care coordinator and the clinical leadership team to ensure the level of care provided and the next site of care are appropriate.

Inpatient Rehabilitation Reviews: Patient cases identified as potential candidates for inpatient rehabilitation are extensively reviewed by both physicians and administrative team members to determine if discharges are clinically appropriate prior to inpatient rehabilitation facility admission.

Readmission Reviews: Cases are reviewed to understand if hospital readmissions were preventable and what factors contributing to such rehospitalizations could be mitigated in the future through new interventions and programs.

Episode Coding Review: Coded MS-DRGs are reviewed to ensure appropriate documentation, coding and billing practices are in place.

Systemwide Care Redesign Initiatives

Health System Standardization: Efforts are being made to standardize educational materials, patient requirements for surgery, surgical pre-optimization/readiness, pre-surgical hospital processes, clinical operator tasks, and decision algorithms to determine the most appropriate next site of care.

Rehabilitation Joint Camp: Patients are offered to engage post-operatively in group rehabilitation sessions alongside their clinical team as well as other patients in a “camp-like” fashion. This inclusive model motivates patients to get back to optimal health more quickly, improves patient experiences, and affords patients and families the ability to more fully engage in their recovery.

High Performance Network: Skilled nursing facilities and home health agencies meeting the highest levels of orthopedic-specific quality performance are selected into a high-performance CJR network tailored to meet the needs of the CJR population and deliver the best outcomes.

 Transition Care Management: Patients will receive care coordination services and assistance with identifying resources when they are discharged home by the centralized outpatient care coordination team. The service focuses on ensuring patients have access to durable medical equipment and that their medications are reconciled, as well as making post-discharge follow-up appointments with primary care and orthopedic physicians.

Optum Spine and Joint Surgery (SJS) Program

In 2018, Orlando Health Network launched a regionally exclusive partnership with Optum (a member of United HealthCare Group) for its Center of Excellence Program known as the Spine and Joint Surgery (SJS) program. OHN is the first and only organization in Florida with such an arrangement, joining a prestigious list of other top orthopedic and neuro-orthopedic providers participating in the program across the country.

The SJS program is a bundled payment arrangement targeted toward commercial patient populations. Under the SJS model, several national and local employers have access to care featuring enhanced member benefits for three types of bundled payment surgical cases, including: (i) hip and knee joint replacement, (ii) lumbar spinal fusion, and (iii) cervical spinal fusion. The principal benefits to employers are cost predictability and the highest possible clinical outcomes.

The major benefits of the program for patients are:

1. Reduced hospital lengths of stay
2. Reduced inpatient readmissions
3. Fewer surgical-site infections
4. Access to dedicated care coordinators
5. Zero/low out-of-pocket member expense