Bundled Payment Changes: Learn What’s New and How to Succeed
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In January, CMS announced the Bundled Payment for Care Improvement Advanced “BPCI Advanced” program, initiating renewed interest in a total cost of care payment model for specific episodes of care. Regardless of your organization’s current decision to participate, it’s important to understand how bundled payment programs have the ability to significantly decrease your internal costs, broaden your revenue opportunities, and improve patient outcomes across specific populations. The Center for Medicare and Medicaid Innovation’s newest iteration of bundled payments provides another tightly-defined program that allows organizations to scale Population Health Management. Best practice suggests that tactical interventions to assess clinical variation, implement strategic care redesign programs, and to adjust care management-facilitated patient stratification models are important to be successful with bundled payments – so knowing how to implement them is crucial. One organization’s savings is another’s income and without making overhead allocation changes, bundled payments may reduce revenue that has been critically important to maintain hospital profitability. Join this webinar to learn: * What is new with bundled payments. * The ramifications bundles can have across organizations. * Leveraging data and strategic analysis to identify opportunities for bundled payment success. * Operationalizing successful care program tactics to be successful in bundled payment contracts.
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Bundled Payment Changes: Learn What’s New and How to Succeed
- 1. Bundled Payment Changes: Learn What’s New and How to Succeed Jonas Varnum - Population Health Management Consultant, Health
- 2. Goals of Today’s Webinar: • Share what’s new with bundled payments • Learn about the ramifications that bundles can have across organizations • Leverage data and strategic analysis to identify opportunities for bundled payment success • Operationalize payment and care transformation tactics to be successful in bundles Agenda Items: • Summary of Bundled Payment Programs • What is Bundled Payments for Care Improvement (BPCI) Advanced? • Data Sources and Organizational Diligence • Operationalizing Bundle Success Agenda
- 3. • Summary of Bundled Payment Programs • What is Bundled Payments for Care Improvement (BPCI) Advanced? • Data Sources and Organizational Diligence • Operationalizing Bundle Success Agenda
- 4. © 2018 Health Catalyst The Challenge: Rising Health Spend…. US Health Expenditures have risen to 18% of GDP 4
- 5. © 2018 Health Catalyst Driving Toward PHM: Definitions Abound 5 ….To A Contract-Based Focus… “Meeting contractual requirements from commercial insurers, Medicaid and the Centers for Medicare and Medicaid (CMS) related to dollars saved and quality metrics upheld in the context of small but growing at-risk contracts, while remaining successful in FFS contracts.” — Partners Healthcare …To An Aspirational Long-Term Goal “The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” — C-E.A. Winslow, Founder, Yale Department of Public Health From The Pragmatic… “The proactive management of the health of a given population by a defined network of financially linked providers in partnership with community stakeholders” — Chilmark Research
- 6. © 2018 Health Catalyst CMS Categories of Payments to Providers and the percentage of payments linked to quality (historical, target) 6 Credit: Partners Center for Population Health Category 1 fee for service – no link to value Category 2 fee for service – link to quality Category 3 alternative payment models built on fee-for- service architecture Category 4 population-based payments 2016 30% 85% 2018 50% 90% 2014 ~20% >80% 2011 0% ~70% GoalsHistorical Performance All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4) FFV (fee-for-value) FFS (fee-for-service) 6
- 7. © 2018 Health Catalyst A Framework for Transformation PHM leadership lays groundwork for a high-functioning analytic platform Analytics leadership builds a structure to identify and evaluate opportunities Financial leadership balances risks and helps set a sustainable course forward Clinical leadership identifies and implements appropriate changes in care delivery KEY ACTIVITIES 1. Ensure baseline understanding of current requirements, goals 2. Interview stakeholders for context 3. Assess available data to identify quick wins, long-term focus areas 4. Synthesize and prioritize opportunities 5. Plan for ongoing evaluation, analysis KEY ACTIVITIES 1. Align PHM with financial plans 2. Look to benchmarks to set expectations 3. Ensure you’re paid for value you provide 4. Pace utilization efforts carefully 5. Increase ability to understand true cost of care KEY ACTIVITIES 1. Streamline your approach to quality measures 2. Optimize care management 3. Shore up primary care infrastructure 4. Seek opportunities for inpatient transformation 5. Ensure appropriate site of care 6. Develop patient engagement strategy • 50+ analytic accelerators in high-opportunity areas (readmissions, sepsis, COPD, joint replacement, CLABSI, CAUTI, labor & delivery, CABG, C. diff, diabetes, SSI, etc.) • Expert guidance on care & payment transformation strategies • Data Operating System (DOS) • 150+ data sources (EMR <10% of data needed) • Patient Stratification • Touchstone • PMPM Analyzer • HCC Insights • CORUS: Activity-based Costing, Cost Insights • Care Management • Community Care • Leading Wisely executive monitoring Near term Meet contractual requirements in FFV contracts Remain successful in FFS business Long term Better quality of care across the continuum Lower costs Stronger organization Healthier community Population Health Management • Opportunity analysis: PHM readiness assessment, key queries/reports • Measures Manager • Population Explorer 1 2 3a 3b KEY ACTIVITIES 1. Prioritize data sources, starting with claims data 2. Educate stakeholders on the available data 3. Define supporting logic—like attribution 4. Invest in staffing 7
- 8. © 2018 Health Catalyst • Bundled Payments – or Clinical Episode Payment Models – pay providers across the continuum of care a single sum of money for a tightly-defined set of clinical services over a set period of time — Adopted from the Health Care Payment and Learning Action Network • In general, CMS’ Medicare initiatives lead bundles adoption, also known as Clinical Episode Payment Models o BPCI Advanced – newest iteration o CJR – scaled-down mandatory models o Oncology Care Model • Other bundle arrangements: commercial and employer settings What Are Bundled Payments 8
- 9. © 2018 Health Catalyst Components of a Bundle • Goal of ACOs: Reduce annual total cost of care across the care continuum • Scale PHM Infrastructure HCPLAN’s Components of Episodes of Care Components of PHM Infrastructures: 9 Source: Health Care Payment Learning & Action Network. (2016). Clinical Episode Payment Models [White paper]. https://www.friends.edu/wp-content/uploads/2015/08/ElectronicReference.pdf Accountable Entity IPA Entity Ind. MDs Hospital / Health System Post- Acute Care
- 10. © 2018 Health Catalyst How Do You Succeed In Bundles? • Post-Acute / Post-Discharge operational changes, waste • Care redesign activities o Examples: Readmission reduction programs, care management and coordination tactics • Patient engagement and education o Multiple levels: Assessments, post-hospital stay Clinical Variation Reduction Care Transformation Tactics 10 • Clinical standardization • Reduce inpatient waste (labor, device, supplies)
- 11. • Summary of Bundled Payment Programs • What is Bundled Payments for Care Improvement (BPCI) Advanced? • Data Sources and Organizational Diligence • Operationalizing Bundle Success Agenda
- 12. © 2018 Health Catalyst • CMS Advanced Alternative Payment Model creates a 90-day episode period for specific “Clinical Episodes” • Maximum risk or gain of 20% • Share in savings if Episode Initiators meet the Clinical Episode’s target price minus a 3% adjustment • Can participate in up to 29 Inpatient Clinical Episodes + 3 Outpatient Clinical Episodes • Seven quality metrics impact shared savings total • Three waivers available BPCI Advanced Overview 12 CMS continues to provide another tightly-defined program that allows organizations to scale PHM tactics to drive costs down and quality up across populations
- 13. © 2018 Health Catalyst BPCI Advanced Bundles 13 Cardiology •Acute myocardial infarction •CABG •Cardiac arrhythmia •Cardiac defibrillator •Cardiac valve •Congestive heart failure •Pacemaker •Percutaneous coronary intervention Gastroenterology •Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis •Gastrointestinal hemorrhage •Gastrointestinal obstruction •Major bowel procedure Joint and Spine •Back and neck except spinal fusion •Cervical spinal fusion •Combined anterior posterior spinal fusion •Double joint replacement of the lower extremity •Fractures of the femur and hip or pelvis •Hip and femur procedures except major joint •Lower extremity/humerus procedure except hip, foot, femur •Major joint replacement of the lower extremity •Major joint replacement of the upper extremity •Spinal fusion (non- cervical) Outpatient •Back or next except spinal fusion •Cardiac defibrillator •Percutaneous coronary intervention Respiratory •COPD, bronchitis, asthma •Simple pneumonia and respiratory infections Other Medical •Cellulitis •Sepsis •Urinary tract infection •Renal failure •Stroke
- 14. © 2018 Health Catalyst How many Episodes of Care does your organization anticipate participating in during 2019? 1. 1-3 — 16% 2. 4-6 — 12% 3. 7-10 — 2% 4. 10+ — 11% 5. Not Applicable — 58% Poll Question 14
- 15. © 2018 Health Catalyst BPCI Advanced Clinical Episode Example 15 Patient admitted to hospital for specific episode Patient discharged to Post-Acute Care Patient discharged home, receives home health Day 1 Day 4 Day 11 Day 25 Day 32 Patient Readmitted to Hospital Patient follow-up appointment with physician Day 90 Bundled Payment ends
- 16. © 2018 Health Catalyst BPCI Advanced Mechanics 16 $0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000 $1,800,000 2013 2014 2015 2016 Part A Part B $0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000 $1,800,000 $2,000,000 Perf Period 1 Perf Period 2 Perf Period 3 Historical Spend Historical Minus Discount BPCI Advanced Baseline Prices (Example) BPCI Advanced Target Prices (Example) -3% -3% -X% 10/1/18 – 6/30/19 6/30/19 – 12/31/19 1/1/2020 – 12/31/20
- 17. © 2018 Health Catalyst All-cause Hospital Readmission Measure (NQF #1789) Advanced Care Plan (NQF #0326) AHRQ Patient Safety Indicators (PSI 90) Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary THA and/or TKA (NQF #1550) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558) Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881) Quality Metrics 17
- 18. © 2018 Health Catalyst May 2018 (June 2018): CMS provides historical claims data and Target Prices • April-May: Initial data validation of Clinical Episode opportunities. Use appropriate available data for first-level analysis • June-July: Use Claims Data and qualitative approach to validate clinical episode opportunities, finalize episode list Submit Clinical Episode list by understanding data and organizational elements • Due: August 1 Submit Care Redesign, Financial Arrangements List, and PGP List • Due: September 3 CMS Timeline and Specific Deliverables 18
- 19. • Summary of Bundled Payment Programs • What is Bundled Payments for Care Improvement (BPCI) Advanced? • Data Sources and Organizational Diligence • Operationalizing Bundle Success Agenda
- 20. © 2018 Health Catalyst Analytically, how have you evaluated BPCI Advanced opportunities? 1. Reviewed BPCI Advanced claims data — 9% 2. Reviewed BPCI Advanced claims data and other claims data sets — 11% 3. Reviewed multiple different data sources (e.g. claims and EMR clinical data) — 27% 4. None of the above — 10% 5. Not applicable — 43% Poll Question 20
- 21. © 2018 Health Catalyst Data Sources EMR and Accounting Clinical and Costing Data • Inpatient volumes, costs, and payments • Limited details across the care continuum Other Claims Files • Highlight post-anchor opportunities • Analysis per bundled payment identifier (e.g. Clinical Episode) • Generally limit analysis to few metrics Health Catalyst Touchstone* (Claims Data) • Compares most impactful opportunities • Benchmarking per Clinical Episode and DRG • Benchmarking only for specific metrics Payer’s Claims Data • Historical data set • Consistent data feeds • Data across care continuum Conduct First-Level Analysis Prior to Receiving Payer-Specific Data Sets Generally Program’s Primary Source of Truth 21
- 22. © 2018 Health Catalyst Health Catalyst Bundles Selection 22 Align Episode of Care selection process with strategic direction, available data and data source opportunities, clinical improvement lines, and PHM goals. 1 2 1. Use data from various data sources to determine opportunities across continuum. 2. Align data with qualitative review. Opportunity Matrix Service Line Bundled Payment Quantitative Findings Qualitative Findings Cardiology Acute myocardial infarction Diabetes Sepsis Readmissions Common, linkable vocabulary Financial Source Marts Administrative Source Marts Departmental Source Marts EMR Source Marts Patient Satisfaction Source Mart FINANCIAL SOURCES (e.g. EPSi, Peoplesoft, Lawson) ADMINISTRATIVE SOURCES (e.g. API Time Tracking) EMR SOURCEs (e.g. Cerner, Allscripts, NextGen) DEPARTMENTAL SOURCES (e.g. Apollo) Pt. SATISFACTION SOURCES (e.g. NRC Picker, Press Ganey) Spreadsheet Silos • Silos or pockets of analysis • Conflicting spreadsheet reports and interpretations of data • Battles over data ownership • Most time spent on hunting for and gathering data
- 23. © 2018 Health Catalyst Health Catalyst Opportunity Matrix 23 Quantitative Internal Findings Qualitative Evaluation Overall Recommendations Service Line Bundled Payment Volume Profile Key Cost Metrics General Impactability KPI Metrics Strategic and Episode-specific Financial Impact Metrics Physician Champion Specialist Readiness Care Management and Transitions Spectrum Evaluation Clinical Impr. Evaluation PAC Impact Opportunity BPCI Advance Participation Outcomes Improvement Only Cardiology Congestive heart failure Other Medical Urinary tract infection Goals of Analysis: • Identify appropriate strategic volume, cost, operational, and financial metrics to determine if organization will be successful in which types of bundles • Include historical trends and anticipated impact based upon provider buy-in and participation goals • Review holistic impact – e.g. would minimal participation still provide meaningful 5% bump through Advanced APM involvement Goals of Analysis: • Determine clinical readiness and buy-in • Identify clinical champions • Define operational interventions required and scalability impact across organization • Review network management and post-acute care opportunities • Identify clinical variation goals ahead of time Goal of Opportunity Matrix: Finalize bundles to green-light versus bundles to focus on internal improvement work only Joint and Spine Major joint replacement of the lower extremity Respiratory COPD, bronchitis, asthma
- 24. © 2018 Health Catalyst Qualitative Assessment Identify strategic and tactical approaches per hospital and service line level Obtain feedback from multiple leaders across centralized and local levels. 24 Domain Example Leaders Physician Representation 1. CMO • 2-4 leaders across validated Service Lines: Cardiology Internal Medicine Neurology Gastroenterology Surgery Urology Hospitalist Care Management 1. Care Management Director 2. Lead Care Manager 3. Transitions of Care Leader Strategic Influence 1. Appropriate C-Suite 2. PHM Executive 3. Strategic Planning Leader Quality 1. Chief Quality Officer 2. Lead Quality Initiative Manager Pop Health Operations Specialists 1. PHM Intervention Leader 2. Post-Acute Care Intervention Leader CM Readiness Assessment PHM Readiness Assessment
- 25. • Summary of Bundled Payment Programs • What is Bundled Payments for Care Improvement (BPCI) Advanced? • Data Sources and Organizational Diligence • Operationalizing Bundle Success Agenda
- 26. © 2018 Health Catalyst Health Catalyst Bundles Selection 26 2 3a 3b 1. Use data from various data sources to determine opportunities across continuum 2. Continuously ingest, analyze, and review data for bundles success Opportunity Matrix Service Line Bundled Payment Quantitative Findings Qualitative Findings Cardiology Acute myocardial infarction • Identify appropriate incentive structure (gainsharing) to maximize clinical changes • Build data systems to understand and project bundle success on regular intervals Payment Transformation • Engage clinical, financial, data, IT teams through appropriate structure / workgroups • Launch operational tactics (e.g. readmission reduction programs) to impact metric success Care Redesign • Identify and refine care management populations specific to selected bundles • Incorporate tailored services – pre- and post- discharge planning – to match patient needs Care Management
- 27. © 2018 Health Catalyst BPCI Adv. Operational Governance Structure 27 Bundles Executive / Steering Committee IT Committee Network Management Committee Example Tasks: 1. Oversee data security, management, and analytics 2. Produce intelligence for success Example Tasks: 1. Utilization management 2. Post-acute alignment Finance Committee Example Tasks: 1. Oversee Gainsharing Workgroup 2. Financial reporting 3. Review reconciliation Scalable across PHM Operations Care Transformation Structure Oversee BPCI Care Redesign and Quality Efforts Example tasks: • Oversee Care Redesign implementation • Oversee protocol implementation • Oversee quality measures and reports • Review data reports • Coordinate across committees Specific Work group (e.g. CHF) Either specific to BPCI or PHM Operations
- 28. © 2018 Health Catalyst How Do You Succeed In Bundles? • Post-Acute / Post-Discharge operational changes, waste • Care redesign activities o Examples: Readmission reduction programs, care management and coordination tactics • Patient engagement and education o Multiple levels: Assessments, post-hospital stay Clinical Variation Reduction Care Transformation Tactics 28 • Clinical standardization • Reduce inpatient waste (labor, device, supplies)
- 29. © 2018 Health Catalyst • 42 Physicians performed 1-5 Episodes • Avg. # of Episodes: 4.2; Median: 2 • 7 physicians accounted for 68% of Episodes • 4 of 7 have consistent outcomes across risk-adjusted population • Other KPIs: Supply cost, LOS, and Readmissions show opportunity • Use Claims data to review care continuum performance Cross Continuum Variation Example 29 Row Labels Clinical Episode Count Congestive Heart Failure 422 Provider A 78 Provider B 66 Provider C 42 Provider D 42 Provider E 38 Provider F 12 Provider G 8 Provider H 7 Provider I 7 5 4 4 4 2 2 2 2 2 2 2 1 1 1 1 EMR and Financial Data Touchstone Benchmarking + Claims and/or EMR Analysis Claims Data Row Labels Clinical Episodes Count Median Total Variable Cost Supply Variance Average of Opportunity Index LOS Obs/Exp (Avg) Avg 30-Day Readmission (Observed/Expected) % of SNF as 1st PAC Prov. SNF Rehospitalization Rate Congestive Heart Failure 422 $6,821 $182,670 2.78 1.38 1.72 22% 12% Provider A 78 Provider B 66 Provider C 42 Provider D 42 Provider E 38 Provider F 12 Provider G 8 All data represented is fictional
- 30. © 2018 Health Catalyst Episode of Care Intelligence Needs 30 • Bundle Data o Dive deeply into chosen bundles’ KPIs and the data behind them o Need to see high-level variation, opportunities, but also drill into claim-line details o Include costing and payment insights, outcome measures, and broad intelligence • Leading Wisely o Proactive notification system that ensures nothing falls through the cracks o Put-out-the-fire daily: If there are outliers that need adjustments, users are emailed as quickly as any source of data is refreshed (cannot just be claims)
- 31. © 2018 Health Catalyst Prerequisites Recruit team Train team 7. Measure Progress 1. Best Practices 2. Define Cohort 3. AIM Statement 4. Design Metrics 5. Rollout Plan 6. Rollout Work Streams • Solicit front line plan input • Finalize analytics dev, testing, and rollout support • Finalize intervention rollout plan • Guidance team validation Rollout • Review initial results • Identify, approve any modifications to intervention rollout • Review lessons learned • Create next AIM statement • Repeat process Results • Finalize cohort • Identify intervention(s) • Direct observation • Solicit front line input on AIM and intervention • Define intervention rollout plan • Guidance team validation Intervention • Review visualized drafts of AIM cohort findings • Identify data quality issues • Direct observation • Prioritize and select AIM #1 • Review cohort criteria and visualizations • Guidance team validation AIM • Confirm team mission, charter, roles • Review AIM options • Gather best practices • Profile and visualize preliminary data • Select 2-3 potential AIMs • Guidance team validation Kickoff Select Build and Refine Build and Refine Build and Refine Rollout Date Major Milestones Care Redesign Required Make sure to include Care Redesign and performance improvement work as a component of BPCI Advanced. Below is an example of the efforts required. 31
- 32. © 2018 Health Catalyst Care Transformation 1. Identify and/or refine the populations targeted for care management 2. Design services and processes to meet those patients’ needs 3. Craft job descriptions for the new care management program, and hire and train staff to take on those roles 4. Leverage technology to identify and register patients, coordinate care and services, engage patients—and then monitor the performance of the program and surface additional areas for improvement 1. Example specifics within Readmission Program 2. Establish communication channels through assessments, technology Care Management Specifics Patient Engagement Tactics 32 Pre-Hospitalization Discuss expectations, care continuum options, care management needs Day 1 of Hospitalization Assess Health Literacy and initiate self- management of condition Inpatient Days pre-discharge Identify post- discharge care continuum providers Review readmission and poor outcome risk- factors Day After Discharge Complete discharge summary and specific cross- continuum follow- up Post-Anchor Period Track patient needs across continuum Provider visits inside SNF, other facilities Care Management Guidebook CM Strategic Conversation Guide Intervention Services for CM Programs
- 33. Q&A