Archive for the ‘Bundled Payments’ Category

5 Reasons for Post-Acute Care to Participate in Bundled Payments

September 1st, 2015 by Patricia Donovan

Bundled payment participation put Brooks Rehabilitation on the forefront of healthcare payment reform.


Having completed more than 1,000 bundled episodes for total hip replacements, total knee replacements and hip fractures, Brooks Rehabilitation has achieved significant savings through Model 3 of the CMS Bundled Payments for Care Improvement (BPCI) Model 3. Here, Debbie Reber, MHS, OTR, vice president of clinical services for Brooks Rehabilitation, explains Brooks’ rationale for participating in episode-based payment models.

Why would post-acute care be responsible for bundled payments, as opposed to the acute care provider? When CMS’s original bundles came out, it looked as though they would all be driven by acute care providers. At the time that Brooks jumped in, there was not a lot of information on what our opportunity would be or how this model was going to look. To explain our rationale for jumping into bundled payments, Brooks decided it was going to participate in order to be on the forefront of learning more about payment reform. We wanted to look at how post-acute care providers could help make some of the healthcare policy changes related to the future of healthcare reimbursement.

Second, we also really wanted to serve as a catalyst for a business to begin working better as a system of care. With all of our different divisions and the way our care settings are spread over the various counties that we serve, sometimes it was difficult for us to work as a united, seamless system. We thought moving to bundled payments offered a great opportunity for us to work better as a system of care, improve our care transitions, and improve our continuum.

Third, the other huge opportunity with bundled payment is the chance to experiment with clinical redesign. We approached bundled payments as having a blank slate: we could redesign the care to look and feel however we wanted it to be. If we could do things all over again, what were the tasks or gaps or cracks in our clinical care that we could really improve upon?

Fourth, we knew we wanted to have a strong voice regarding future policy and payment reform changes. And finally, we wanted to show that, in addition to key providers, Brooks was sophisticated enough to take risk and play a primary role with that continuum of care.

Source: Bundled Payments for Post-Acute Care: Profiting from Alternative Payments and Clinical Redesign

post-acute care bundled payments

Bundled Payments for Post-Acute Care: Profiting from Alternative Payments and Clinical Redesign shares the inside details of Brooks’ Complete Care program and the resulting, significant savings Brooks achieved through CMS’s BPCI Model 3, which is limited to retrospective post-acute care (PAC) for select diagnosis-related groups (DRGs).

Post-Acute Care Improvement: 9 Trends to Know

August 25th, 2015 by Patricia Donovan

post-acute care trends

Healthcare favors a unified cross-setting PAC payment system, according to 2015 PAC metrics from the Healthcare Intelligence Network.


Across the continuum of post-acute care (PAC) providers—defined as skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs)—skilled nursing is the sector most in need of reform, say 40 percent of healthcare organizations who responded to a 2015 survey on Post-Acute Care Trends.

Also in need of revamping are PAC payment models, the Healthcare Intelligence Network survey determined. While 53 percent have already incorporated PAC services into value-based reimbursement methodologies such as an accountable care organization (ACO) or shared savings arrangement, 60 percent of respondents would like to see Medicare adopt a unified cross-setting PAC payment system that would follow the patient across care sites.

Already participating in Models 2 and 3 of CMS’s ongoing Bundled Payments for Care Improvement (BPCI) initiative, PAC providers are also gearing up for closer scrutiny of skilled nursing facility (SNF) readmission rates by Medicare beginning in 2018. The federal payor has been monitoring 30-day hospital readmission rates since 2012, gradually expanding the list of applicable readmissions measures and scaling readmission reimbursement.

The top tactics to improve quality, enhance care coordination and reduce spend associated with post-acute care include care transition management, development of PAC partnerships and integration of all PAC services, say respondents.

Here are five more metrics from HIN’s 2015 Post-Acute Care Trends survey:

  • A case manager helms PAC improvement initiatives for 38 percent of respondents.
  • Patient transitions between care sites is the top PAC challenge, say 25 percent of respondents.
  • Half of responding organizations say heart failure and shock are the most challenging health conditions to manage in PAC settings.
  • Eighty-five percent of respondents said care coordination improved as a result of these efforts, while 36 percent observed a decline in hospital readmissions from PAC facilities.
  • The INTERACT™ (Interventions to Reduce Acute-Care Transfers) program and tools, designed to reduce the frequency of PAC transfers to acute hospitals, are frequently cited by respondents as critical to PAC coordination. The INTERACT tool was initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP, at the Georgia Medical Care Foundation.

The post-acute care arena is rich with opportunity for improvement, agreed many respondents.

“PAC is the blockbuster drug the U.S. healthcare system has been waiting for,” concluded one survey respondent, noting that post-acute care provides big financial levers for provider organizations to align clinically, financially and operationally. “Forward-thinking providers are organizing to amass large pools of manageable risk and recalibrating to optimize care delivery and share meaningfully in the medical expense reduction associated with better more effective and patient centric care. This is a win all the way around.”

Download an executive summary of 2015 PAC survey results.

Post-Acute Care Payment Bundles: Catalyst for Clinical Redesign, Improved Care Transitions

July 30th, 2015 by Melanie Matthews

Brooks Rehabilitation jumped at the opportunity to participate in CMS’ Bundled Payments for Care Improvement (BPCI) program to be at the forefront of learning more about healthcare payment reform, said Debbie Reber, MHS, OTR, vice president of clinical services, Brooks Rehabilitation.

We saw it as an opportunity for post-acute care providers to help make some of the healthcare policy changes related to the future of healthcare reimbursement. We also really want it to serve as a catalyst for our business to begin working better as a system of care, Ms. Reber explained during last month’s webinar, Bundled Payments for Post-Acute Care: Four Critical Paths To Success, a Healthcare Intelligence Network webinar now available for replay.

Post-Acute Care Payment Bundles: Catalyst for Clinical Redesign, Improved Care Transitions

Brooks Rehabilitation achieves 19 percent savings over historic spend and reduces readmission rates to 15 percent through Bundled Payments for Care Improvement Program.

“Our move toward bundled payments was a great opportunity to improve our care transitions, our continuum,” said Reber. “The other huge opportunity is to experiment with clinical redesign. As we approached bundle pay, we approached it with ‘we have a blank slate. We can redesign the care to look and feel however we want it to be. If we were doing things all over again, what are the things or the gaps or cracks to the clinical care that we could really improve upon?'”

“We knew that we wanted to have a strong voice regarding future policy and payment reform changes. We really wanted to show that we were sophisticated enough to take risk and play a primary role with that continuum of care,” she added.

Brooks is serving under CMS’ Model 3, in which it selects from a list of DRGs. It started in October 2013 with fractures, hip and knee replacements as well as hip and knee revisions.

Brooks added congestive heart failure, non-cervical and cervical fusions and back and neck surgery bundles this past April.

“All of our bundles are for an episode length of 60 days with the only exception to that being congestive heart failure. We did heart failure for 30 days just due to the tremendous risk of managing those cases and to decrease our risk overall with that population,” Reber explained.

Brooks begins its process when the patient leaves the acute care facility.

“We are then responsible for all non-hospice Part A and B services, including physician visits, DME, medications, post-acute therapy or rehab services, as well as any readmission,” she said. Of particular note is that the readmissions are not just related to the acute episodes that we are seeing them for…it’s for any reason that the patient would be readmitted.

Understanding what those readmission reasons are is huge to our success, Reber explained. For example, on the orthopedic side, even though the patients have just been seen for an orthopedic surgery, the primary reason for readmission is predominantly around cardiac issues or pulmonary issues that are more likely due to prior comorbidities. It’s really just managing those issues more.

Brooks has achieved an overall savings of about 19 percent over its historic spend and has decreased its readmission rate to about 15 percent across the 60-day time frame within this program. And, has also seen increases in patient functional improvement and patient satisfaction rates.

During the webinar, Reber walked participants through the four domains that have been critical to its success in the BPCI program, including: using standardized assessments across care settings; patient and caregiver engagement; the in-house developed Care Compass Tool, which includes a longitudinal care plan; and enhancing the role of the care navigator.

Integrated Networks Trigger Rise in Post-Acute Care Accountability

June 25th, 2015 by Patricia Donovan

Healthcare is examining new post-acute care (PAC) delivery and reimbursement models.

As physician-hospital associations (PHOs) and clinically integrated networks increasingly monitor referrals and where patients go once they leave the office or hospital setting, the post-acute care market will be held more accountable for the quality and cost of care they provide and their ability to manage readmissions, predicts Travis Ansel, senior manager with the Healthcare Strategy Group. Here, Ansel suggests how PHOs might prepare for the eventual inclusion of post-acute care in their networks.

Healthcare Strategy Group did a lot of work in Arkansas in 2011 and 2012. As providers started being held accountable for what happened once their patients left the hospital, post-acute care became very relevant in the Arkansas market. This was due to the impact on the providers, and on the physicians of the hospitals in that market. Almost immediately upon the announcement of the models, the hospital started bringing in different post-acute care organizations, saying, These are our incentives. We’re trying to manage patients who have been assigned these diagnosis-related groups (DRGs). We’re trying to manage these factors for those patients. Either you’re going to be the one to help us to do it, or we’ve going to find someone else in the market to do it.

My general expectation would be that as hospitals and physicians get together and start talking more about how post-acute care affects them, we’ll see them bringing in post-acute care to have that discussion: either help us with what we’re being held accountable for, or we will find someone else who can.

The natural market reaction to that is post-acute care organizations will either compete to respond to those requirements, because there will be some opportunity to grow market share or grow reimbursement if they’re effective in responding to those things.

We’ve already seen a tremendous amount of consolidation in the post-acute care world over the last five to ten years. To me, that would signal a lot more consolidation, the same as we’ve seen with the provider market. They’re going to look for a capital infusion and build competencies that will help them respond to PHOs’ requests.

Note: Have more thoughts on the rise of accountability for post-acute care? Answer 10 Questions on Post-Acute Care Trends.

Source: Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement

Travis Ansel, MBA, is a Manager, Strategic Services with Healthcare Strategy Group, LLC, with a primary focus on hospital strategic planning, physician alignment planning and clinical integration.

Infographic: Enterprise Population Health Management

May 11th, 2015 by Melanie Matthews

Healthcare risk is shifting from payors to providers, according to a new infographic by Caradigm.

The infographic outlines the different models that providers can use to assume risk and how organizations can coordinate care in an integrated community, which is critical to risk assumption.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability In today’s value-based healthcare sphere, providers must not only shoulder more responsibility for healthcare outcomes, cost and quality but also align with emerging compensation models rewarding these efforts—models that often seem confusing or contradictory. The challenges for payors and partners in creating a common value-based vision are sizing the reimbursement model to the provider organization and engaging physicians’ skills, knowledge and behaviors to foster program success.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability examines a set of provider compensation models across the collaboration continuum, advising adopters on potential pitfalls and suggesting strategies to survive implementation bumps.

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PHOs Let Quality, Cost Guide Them Toward Value-Based Reimbursement

April 16th, 2015 by Cheryl Miller

Instead of focusing on volume, physician-hospital organizations (PHOs) are concentrating on value-based care, says Travis Ansel, senior manager with the Healthcare Strategy Group. The once revenue-based organizations are now focused on quality and cost, realizing that if they can’t manage those two things, their reimbursement will go down.

Why is the PHO model going to work now? We always get this question. This comes more from doctors than it does from administrators: why are PHOs going to work now, when they didn’t work before? The simple answer is that before, PHOs were revenue-focused. They were about getting the biggest number of physicians into the model regardless of their quality. It was run by the hospital as a methodology for increasing rates. Then fee-for-service (FFS) didn’t really give anybody the incentive to work together.

They gave everybody the incentive to sign their name on the contract and hope for better rates. What we’re seeing PHOs focus on now is quality and cost, with the idea that if they can’t manage those two things, their reimbursement is going to go down. We have clinical integration guidance from the Federal Trade Commission (FTC), which gives everybody the framework for developing joint contracting capabilities and defines legally how we can work together. What we’re seeing now, since there’s more of a clinical than a revenue focus for PHOs, is that they are more dominated by physician leadership. The hospital keeps control over the purse strings, but gives the governance of the group to physicians. They are letting them take the leadership on the cost and quality protocols that they need to develop to be successful.

There is also the way that payment reform is transitioning the incentives. They’re focused on getting quality and cost across populations or across episodes of care. They’re giving the right incentives for collaboration, which the PHO model provides the forum for.

Source: Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement

Home Visits

Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement describes the relevance of the PHO model to today’s healthcare market, offering strategies to leverage the physician-hospital organization for maximum clinical outcomes, competencies and value-based reimbursement.

8 Effective PCMH Tools to Protect the Medical Home Investment

March 19th, 2015 by Cheryl Miller

The patient-centered medical home (PCMH) model is one of the top five investments in 2015, according to Accenture’s recent analysis of government-sponsored State Health Innovation Plans. Researchers from Accenture found that states are investing in PCMHs in order to strengthen primary care integration with specialists and community health workers. Most will also integrate physical and behavioral care.

Embedding care coordinators in physician offices so they can work with case managers is one way to achieve this integration, according to respondents to the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN). We asked survey respondents what other tools they felt were most effective in implementing the medical home. Following are their responses:

  • Electronic communications that include actionable data and access to patients to initiate the change, and a focus on minimal hassle to physician office.
  • The NCQA PCMH tool.
  • Pre-visit planning and ‘huddles.’
  • Patient registries.
  • Monitoring. We fundamentally changed how we operate daily and monitor change. We incorporated our goal measures into the very fabric of what we do.
  • Using templates in electronic medical records (EMRs) for pre-visit planning and coordination of relevant visits.
  • Home care nurse management system.
  • Patient-centered scheduling.

Source: 2014 Healthcare Benchmarks: The Patient-Centered Medical Home

http://hin.3dcartstores.com/Remote-Monitoring-of-High-Risk-Patients-Telehealth-Protocols-for-Chronic-Care-Management_p_5008.html

2014 Healthcare Benchmarks: The Patient-Centered Medical Home is the Healthcare Intelligence Network’s in-depth analysis of medical home adoption, tools, technologies, challenges, benefits and outcomes. Based on HIN’s PCMH survey administered in February 2014, this resource takes the industry’s pulse on patient-centered activity. Now in its seventh year, it is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

7 Characteristics of a Successful Case Manager

March 3rd, 2015 by Cheryl Miller

What qualities are needed for a successful case manager? A background in community nursing helps, because the case manager can better place themselves in the patient’s shoes, having worked with others from the same background, says Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care. Prior experience in home healthcare is also beneficial for case managers, as is having helped patients through major illnesses, and then transitioned them back to work or home.

I want to talk about the qualities of a successful case manager. You want to have an independent thinker because you’re going to be doing a lot on your own. You’re in a practice by yourself. It’s the way we’re set up, but of course, we call each other if we have a question.

You want self-motivation for the same reasons, because you want somebody that is going to be motivated to help the patients and be able to think outside the box.

You need a strong skill set. I’ve found that a good home health background or experience in community nursing helps the case manager determine what a patient might need, because you’ve seen that in the community.

We have several home health nurses at work for us. We have a hospice nurse that works for us and a nurse that worked with insurance claims and worker’s comp. They all have some background where they’ve helped people get through an illness and transition either back to work or get back to where they were before their illness.

Of course, you want a confident nurse, and you need somebody that has the great passion for helping people and is strong willed. You want to take care of the patients, so you’re not popular all the time with the providers. We’re really an advocate for our patients. We’re not always telling them what they want to hear.

If providers don’t have room on their schedule, sometimes we’re really begging for them to see a patient. You have to have good communication skills, be determined to take care of the patients because that is our goal as they transition back to their home or from the facilities. As you know, the personalities are strong in our field of nursing. With the providers, we are in a position sometimes to be a little forceful.

Source: Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols (Webinar available for replay)

http://hin.3dcartstores.com/Embedded-Case-Management-in-Primary-Care-and-Work-Sites-Referral-Stratification-and-Protocols-a-45-minute-webinar-on-September-25-2014-now-available-for-replay_p_4955.html

Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols presents Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care, as she shares how embedded case managers in both primary care practices and work sites are improving the quality of care and reducing healthcare costs by increasing preventive care measures at the work sites and improving care gaps for patients managed by the primary care practice.

12 Things to Know About Chronic Care Management

February 24th, 2015 by Cheryl Miller

Despite new CPT codes that reimburse physician practices for select chronic care management (CCM) services, almost half of healthcare organizations lack a formal CCM program, leaving critical reimbursement dollars on the table, according to 125 respondents to the Healthcare Intelligence Network’s (HIN) 2015 Chronic Care Management survey, conducted in January 2015.

However, 92 percent of respondents believe the Medicare CCM reimbursement codes that became effective January 1, 2015 will prompt equivalent quality overtures from private payors, underscoring care coordination’s importance in a value-based healthcare system.

We also asked respondents how they structured their CCM programs, and who had primary responsibility for CCM services. Following are their responses.

  • Almost 45 percent of respondents to HIN’s 2015 CCM survey have yet to launch a CCM initiative, the survey determined.
  • A diagnosis of diabetes is the leading criterion for admission to a CCM initiative, said 89 percent of respondents with existing CCM programs.
  • A primary care physician or healthcare case manager most often bears primary responsibility for CCM, say 29 percent of survey respondents.
  • Just over one-third of respondents — 35 percent — are currently reimbursed for CCM-related activities.
  • Patient engagement is the most difficult challenge of CCM, according to one-third of survey respondents.
  • The majority of CCM tasks are conducted telephonically, say 88 percent of respondents.
  • Almost three-quarters of respondents — 72 percent — admit patients with hypertension to CCM programs, respondents said.
  • Healthcare claims are the most frequently mined source of risk-stratification data for CCM, say 72 percent of respondents.
  • More than half of respondents — 51 percent — include palliative care or management of advanced illness in CCM programs.
  • On average, each CCM patient is seen monthly, say 29 percent of respondents.

Source: 2015 Healthcare Benchmarks: Chronic Care Management

http://hin.3dcartstores.com/2015-Healthcare-Benchmarks-Chronic-Care-Management_p_5003.html

2015 Healthcare Benchmarks: Chronic Care Management captures tools, practices and lessons learned by the healthcare industry related to the management of chronic disease. This 40-page report, based on responses from 119 healthcare companies to HIN’s industry survey on chronic care management, assembles a wealth of metrics on eligibility requirements, reimbursement trends, promising protocols, challenges and ROI.

Leveraging the PHO Model for Bundled Payment Success

February 5th, 2015 by Cheryl Miller

As Medicare begins its ambitious timeline for moving Medicare payments from volume- to value-based models, alternative payment formulas, including bundled payment arrangements for episodes of care, which CMS has tested in a range of pilots in recent years, will come to the forefront. Here, Travis Ansel, senior manager of the Healthcare Strategy Group, explains why the physician-hospital organization (PHO) provides an attractive framework for bundled payment models.

Bundled pricing is appearing in more and more markets across a number of payors. As I’m sure everyone knows, CMS is testing bundled payment pilots across the country. A number of our clients that have been involved with that have had a reasonable amount of success. Overall, the level of success of the bundled pricing pilot program for CMS leaves one to wonder: is that the future of CMS? Is it some combination of accountable care organizations (ACOs) and bundled payments?

Another interesting program for bundled payments is what’s going on in Arkansas with the Healthcare Payment Improvement Initiative. In this program, the state Medicaid program and Blue Cross have actually worked together to create bundled payments for episodes of care based around high volume diagnosis-related groups (DRGs). The responsibilities for hitting the cost targets in this case are assigned to what they refer to as the “principal accountable provider.” For example, for DRG 470, major joint, the principal accountable provider is the orthopedic surgeon, but the orthopedic surgeon in this case was being held accountable for what goes on in his or her practice.

What goes on before surgery? What goes on during the hospitalization and the surgery, and then what happens 30-90 days post-acute care? They’re being held accountable for care across the continuum. This is relevant to the PHO model, because as this is phased into a number of DRGs—it started with eight, but now it includes quite a few more—the need for a PHO model will bring these physicians together.

PHO Models
Travis Ansel, MBA, is manager of strategic services with Healthcare Strategy Group, LLC. Ansel’s practice focuses on helping hospitals and health systems with physician alignment issues through strategic planning initiatives, such as hospital strategic planning, employed physician group strategic planning, physician alignment planning, and clinical integration. Mr. Ansel holds a master’s of business administration from Vanderbilt University, and bachelor of science degrees in finance and business management from the University of Tennessee.

Source: Preparing for Value-Based Reimbursement Models: PHO Development for ACOs, Bundled Payments and Direct Contracting