Posts Tagged ‘Value-Based Reimbursement’

Infographic: 2018 Alternative Payment Model Trends

November 8th, 2019 by Melanie Matthews

In 2018, 35.8 percent of United States’ healthcare payments, representing approximately 226.5 million Americans and 77 percent of the covered population, flowed through alternative payment models, according to a new infographic by the Health Care Payment Learning & Action Network.

The infographic examines the types of models and their market share.

11 Profitable Value-Based Reimbursement Models: Lessons from Early AdoptersCMS’s ambitious agenda for moving Medicare into alternative payment models is driving the U.S. healthcare system toward greater value-based purchasing at a furious rate. Private payors also have pledged to continue to shift payments away from fee for service and into alternative payment models such as accountable care organizations (ACOs). Fortunately, many healthcare organizations are already exploring value-based payments—often a single innovation at a time—testing models that reward providers for meeting Triple Aim goals of improving patient experience and population health while reducing healthcare’s per capita cost.

11 Profitable Value-Based Reimbursement Models: Lessons from Early Adopters encapsulates nearly a dozen such approaches, from Bon Secours’ building of a business case for its multidisciplinary care team to the John C. Lincoln ACO’s deep dive into data analytics to identify and manage the care of high-risk, high-cost ‘VIP’ patients to ‘beat the benchmark’ to WellPoint’s engagement of specialists in care coordination.

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Infographic: Four Ways To Navigate the Changing Landscape in Value-based Healthcare

September 27th, 2019 by Melanie Matthews

Value-based healthcare is, by all signs, the future of providing, and getting paid, for healthcare. Recent research indicates that hospitals are experiencing success by emphasizing several action areas, with changing mindsets being as important as altering operational models, according to a new infographic by Tork.

The infographic provides four opportunity areas every hospital manager or administrator should consider.

11 Profitable Value-Based Reimbursement Models: Lessons from Early AdoptersCMS’s ambitious agenda for moving Medicare into alternative payment models is driving the U.S. healthcare system toward greater value-based purchasing at a furious rate. Private payors also have pledged to continue to shift payments away from fee for service and into alternative payment models such as accountable care organizations (ACOs). Fortunately, many healthcare organizations are already exploring value-based payments—often a single innovation at a time—testing models that reward providers for meeting Triple Aim goals of improving patient experience and population health while reducing healthcare’s per capita cost.

11 Profitable Value-Based Reimbursement Models: Lessons from Early Adopters encapsulates nearly a dozen such approaches, from Bon Secours’ building of a business case for its multidisciplinary care team to the John C. Lincoln ACO’s deep dive into data analytics to identify and manage the care of high-risk, high-cost ‘VIP’ patients to ‘beat the benchmark’ to WellPoint’s engagement of specialists in care coordination.

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Infographic: Turning Data into Actionable Value-Based Care Insights

April 19th, 2019 by Melanie Matthews

In today’s healthcare economy, value-based care remains top of mind for payers and providers alike. However, misalignment between payers and providers can hinder their ability to achieve cost and quality goals, according to a new infographic by MedeAnalytics, Inc.

The infographic examines obstacles to alignment, the role of analytics in value-based care and perceived misalignment.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results documents the accomplishments of CHS’s 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.

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Infographic: Transitioning to Value-Based Care

April 17th, 2019 by Melanie Matthews

Market and regulatory pressures continue to drive health systems toward value-based payment models. In a survey of leading health systems, half of executives state that the shift to value-based care is happening either quickly or very quickly at their organization. Moreover, respondents indicate that 23 percent of total care delivery in the last quarter of 2018 was value-based, up 5 percent from 2017, according to a new infographic by Lumeris.

The infographic examines the acceleration of the transition to value-based reimbursement.

11 Profitable Value-Based Reimbursement Models: Lessons from Early AdoptersCMS’s ambitious agenda for moving Medicare into alternative payment models is driving the U.S. healthcare system toward greater value-based purchasing at a furious rate. Private payors also have pledged to continue to shift payments away from fee for service and into alternative payment models such as accountable care organizations (ACOs). Fortunately, many healthcare organizations are already exploring value-based payments—often a single innovation at a time—testing models that reward providers for meeting Triple Aim goals of improving patient experience and population health while reducing healthcare’s per capita cost.

11 Profitable Value-Based Reimbursement Models: Lessons from Early Adopters encapsulates nearly a dozen such approaches, from Bon Secours’ building of a business case for its multidisciplinary care team to the John C. Lincoln ACO’s deep dive into data analytics to identify and manage the care of high-risk, high-cost ‘VIP’ patients to ‘beat the benchmark’ to WellPoint’s engagement of specialists in care coordination.

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Infographic: Alternative Healthcare Payment Model Trends

February 13th, 2019 by Melanie Matthews

Public and private health plans, managed Medicaid fee-for-service (FFS) states, and Medicare FFS voluntarily participated in a national effort to measure the use of Alternative Payment Models (APMs) as well as progress toward the Health Care Payment Learning & Action Network’s (LAN) goal of tying 30 percent of U.S. healthcare payments to APMs by 2016 and 50 percent by 2018, according to a new infographic by the Health Care Payment LAN.

The infographic examines APM trends for commercial, Medicare Advantage, Medicare fee-for-service and Medicaid populations.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Clinical Documentation to Optimize Value-Based Care in the Outpatient Setting

June 22nd, 2018 by Melanie Matthews

A strong commitment to clinical documentation improvement (CDI) can help healthcare organizations maximize claims reimbursement while improving quality of care, according to a new infographic by Galen Healthcare Solutions.

The infographic examines CDI goals and the impact of improved CDI on the healthcare bottom line.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: The Impact of a Changing Reimbursement Landscape

June 18th, 2018 by Melanie Matthews

Most healthcare providers revealed that they wouldn’t drop a contract with a payer even if they knew they were underpaid, according to a new infographic by BillingParadise.

The infographic details recent trends in the reimbursement climate and industry changes that are having an impact on how providers are reimbursed.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM RevenueSince the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM.

Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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Guest Post: Demonstrating High Quality Care Becomes Paramount in Bundled Payment Models

April 24th, 2018 by Shane Wolverton

Optimizing bundled payment model opportunities.

The Centers for Medicare and Medicaid Services’ (CMS) cancellation of the mandatory payment bundles for cardiac care, surgical hip and femur fracture treatment in late 2017 is expected to be replaced in 2018 with a voluntary program, called the Bundled Payments for Care Improvement Advanced (BPCI).

CMS also cancelled the cardiac rehabilitation incentive payment model and switched participation requirements in the Comprehensive Care for Joint Replacement (CJR) model from mandatory to voluntary while reducing the selected geographic areas from 67 to 33.

In the BPCI Advanced model, providers will be expected to share in the financial risk and redesign of care delivery to reduce expenditures while maintaining or improving performance on specific quality measures.

CMS’ decision regarding payment under the CJR model that allows total knee arthroplasty to be performed in outpatient settings has caused considerable concern for providers in the acute care setting due to potential loss of revenue to lower cost care settings. Despite these uncertainties, some hospitals under the CJR model have reduced spend per episode and implant costs by over 20 percent.

Regardless of the programs offered by CMS in 2018, providers should focus on finding ways to optimize the bundled payment opportunity with self-funded employers or other plan sponsors as they look to bundles for lowering spend and improving quality. Many of these arrangements require providers to implement stop-loss that assumes risk for utilization beyond the bundled rate. With bundles now offered by ambulatory surgery centers consistent utilization and quality performance becomes paramount. There are numerous organizations scaling to meet increasing demand for this type of value-based care ushering in greater competition.

Maximizing the Benefits of Bundled Payments

The key to success depends on the ability of the organization to foster multi-disciplinary teamwork organized around more refined episodic analysis looking at structure, process indicators and outcomes. These advanced analytics serve as the roadmap to thrive with this payment model. It is vital that the analytics be clinically focused and risk adjusted to determine whether variation is manageable or due to the clinical and demographics of the patients.

Four Steps

First, identify physician leaders to guide the study of current practice patterns, patient throughput and post-acute care. While the physicians facilitate this process, it is recommended that nursing, supply chain, pharmacy and other stakeholders be included.

Second, develop the analytic tools to assess care across the continuum using claims, EMR, and process and patient reported outcomes. Organizations should look for analytics that allow stakeholders to see severity-adjusted episode of illness across the entire continuum of patient care. Accurately comparing the total cost and utilization of medical services against peer groups, national norms, and best practices is important as the trend in bundles is to cover post procedural spend for as long as 90 days. It is essential to compile analytics refined enough to define the current performance and model the expected bundled rates and outcomes. If this step is not performed rigorously, the organization faces considerable risk and discontentment by stakeholders.

Third, determine how the bundles rate will be distributed to the physicians and facilities. This must include incentives for improvement for all stakeholders as margins improve and quality increases.

Fourth, educate the patients and families, as key stakeholders to empower them to work as part of a coordinated team. Providing clear information about the episode can reduce anxiety and improve adherence to recommended therapies and medications pre and post-surgery. Using navigators is a proven approach to help patients through the episode of care.

Patient Selection

As the journey into bundled care begins with the selection of patients best suited for this type of care, it is advantageous to build a repeatable and evidence-based approach to delivering this care. More variability in the clinical and demographic attributes of the patient leads to greater potential variance in treatment. It is vital that the teams develop a consistent care path especially early into the program. This fosters the knowledge required to set utilization and quality outcomes firmly in alignment with the bundled rate. Even the slightest inconsistencies can have significant impact on the programs performance.

Healthcare Performance Management & Analytics

With bundled payments, providers and healthcare delivery organizations benefit from the savings, provided the outcomes of the patient meet expectations. There are some arrangements where quality performance guarantees are included as part of the agreement. For instance, one of the most comprehensive arrangements is the inclusion of a lifetime guarantee for hip arthroplasty. As more care moves from the acute care setting into ambulatory surgery centers or hospital outpatient departments the price of bundles will be commoditized and attractive margins harder to maintain. Patients may also believe that lower cost settings of care may also translate to the delivery of lower quality of care. This puts tremendous pressure on hospitals to begin diligent work on bundles knowing they have a cost disadvantage compared to outpatient settings. Demonstrating high quality care to patients regardless of setting will foster greater trust with employers and payers and reduce the reluctance for patients to seek treatment in the outpatient setting.

Assessment of risk adjusted mortality, complications and unanticipated readmissions along with Agency Healthcare Research and Quality patient safety indicators is essential in building and maintaining a bundled program. These indicators must be risk adjusted properly to validate performance, remediate poor outcomes, credential providers and market the program. The use of statistical process control techniques is also required to discern random versus special cause variation in utilization or outcomes. It would be desirable to use methods published in peer reviewed journals for integrity with the medical staff.

As plan sponsors look for lower cost settings, the quality of care delivered becomes even more important since partnering with a low quality facility may impact the success of this program and their bottom line. Providers that can share their level of safety and performance measures based on reliable and comprehensive analytics will be in a far better position to attract patient volume with better outcomes.

About the Author:

Shane Wolverton

Shane Wolverton is SVP Corporate Development at Quantros. He is responsible for establishing business partnerships for the company and is a sought after speaker on a wide range topics around value-based healthcare delivery.

With over 25 years of deep domain expertise in the use of clinically and risk-adjusted medical analytics he works with many stakeholders in healthcare including employers, brokers, benefits consultants, vendors & providers. He is currently working with numerous organizations leading the movement toward value-based care through high performance networks, COEs, transparency, consumer navigation, bundles of care and network optimization. In addition, he advises hospitals, and physicians, in the use of advanced analytics to drive clinical performance improvement, clinical documentation improvement and performance based marketing communications.

Prior to joining Quantros, Mr. Wolverton served as senior vice president of corporate development at Comparion Medical Analytics. He also served as a management consultant with Health Care Investment Analysts (now IBM Truven Health Analytics) and the McGraw-Hill Healthcare Management Group. He received his undergraduate degree from Auburn University.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remains with them. The company accepts no liability for any errors, omissions or representations.

Mounting Pressure from Value-Based Reimbursement Models Drives Clinical Improvement Strategy at Allina Health System

April 17th, 2018 by Melanie Matthews

Value-Based Reimbursement Models Drive Clinical Improvement Strategy

As a greater percentage of hospital payments are through value-based contracts, hospitals that reduce costs while maintaining quality will survive, predicts Pam Rush, cardiovascular clinical service line program director at Allina Health.

“How do we improve outcomes and decrease costs?” Rush asked participants in the March 2018 webinar, Predictive Healthcare Analytics: Four Pillars for Success. “We need to start to look at the world differently.”

How can we be more creative and do things differently? How can we use different members of the healthcare teams in new ways, such as nurse practitioners or advanced practice providers, she added. In addition, “we need to invest in data analytics and data resources and have data analysts who can pull the information for us so we can find the variation. We need to invest in physician and caregiver time to look at the data, to make changes in how they improve care, to monitor and see what is working and what doesn’t work.”

These four pillars…population health management, reducing clinical variation, testing new care processes and new models of payment, and leveraging cutting edge technologies…have been critical to the work at Allina Health System’s Minneapolis Heart Institute Center for Healthcare Delivery Innovation, said Rush.

In population health management, we’re looking at how can we focus on adherence to guidelines, identify where there are gaps in care and partner with people across the system, primary care and specialists, to improve consistency and adherence to guidelines, she explained.

Allina is reducing clinical variation by looking at unnecessary variations in care where there is inconsistent care without an influence on outcomes.

“We’re also looking at new ways of doing things. How can we use our nurse practitioners, how do we care for patients once they’re discharged from the hospital and bring them back in for clinic visits? It’s really looking at the care model and how we can do things differently to reduce total cost of care,” she said.

In cardiology, there are so many new devices, procedures and techniques to monitor, said Rush, but we need to figure out who are the right providers to do that monitoring, who are the right patients to do these expensive procedures on and who achieves the best outcomes, because we can’t afford to do all of this new technology to every single person.

Allina looks at these four pillars across the continuum. Starting in primary care to partner on prevention strategies, moving to who gets referred to cardiology, and when they’re referred to cardiology, what are the set of tests or treatments and guidelines to adhere to along the continuum to subspecialties, emergency services and all the way up through advanced therapies, such as transplant.

During the webinar, Rush along with Dr. Steven Bradley, cardiologist, MHI and associate director, MHI Healthcare Delivery Innovation Center, shared these four pillars of predictive analytics success along with details on creating a culture of quality and innovation, building performance improvement dashboards, as well as several case examples of quality improvement initiatives contributing to these savings and much more.

Listen to Ms. Rush describe how MHI leveraged an enterprise data warehouse to identify care gaps and clinical quality improvement opportunities.

Infographic: Economic Investment and the Journey to Value-Based Healthcare

December 1st, 2017 by Melanie Matthews

Value-based payment and care has left a powerful and indelible footprint on the U.S. healthcare system. Widescale provider and payer investment in IT infrastructure and personnel to support alternative payment models, an infusion of venture capital support into new technology-based third-party partners, and innovative employer arrangements with providers, are tangibly shifting the axis of healthcare spending, according to a new infographic by the Health Care Transformation Task Force.

The infographic examines how value-based healthcare impacts patients, providers, payers and purchasers.

Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and MethodologyIf one trend has transformed the healthcare industry post-ACA more than any other, it is the market’s new business model rewarding value over volume.

Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and Methodology provides a framework for healthcare’s new value proposition, with advice from thought leaders steeped in the delivery and reimbursement of value-based care. Click here for more information.

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