Value-Based Payment Webinar Series: #2 Bundled Payments as a Platform to Understanding LeadingAge New York Brian Ellsworth, MA, Director, Payment Transformation Beth Carlson, EdD, RN, NHA, Director, Consulting Services Health Dimensions Group HDG 2016 Your Presenters Today Brian Ellsworth, MA Director, Payment Transformation Health Dimensions Group Beth Carlson, EdD, RN, NHA Director, Consulting Services Health Dimensions Group HDG 2016 1 2016 Health Dimensions Group 1
Second in a Series of Four Webinars Webinar 1 Webinar 2 Webinar 3 Webinar 4 What Value- Based Purchasing Means to Post-Acute and LTC Bundled Payments as a Platform to Understanding Value-Based Purchasing New Models of Care Under Value-Based Purchasing Understanding Risk in a Value-Based World HDG 2016 2 Structure for Today s Presentation Where Bundling Fits into VBP Landscape Medicare Bundling: BPCI and CJR Acute and Chronic Bundling for Medicaid Strategies for Bundling Success HDG 2016 3 2016 Health Dimensions Group 2
Number of Bundling Models Continues to Grow Medicare Comprehensive Care for Joint Replacement (CJR) Medicare Bundled Payments for Care Improvement (BPCI) Commercial Medicaid Medicare Managed Care HDG 2016 4 Bundling Comes in Many Shapes and Forms Can be triggered by presence of chronic condition or occurrence of acute event Medicare has focused on episodes after an acute hospitalization (e.g., Bundled Payments for Care Improvement triggered by 1 of 48 hospital events) Medicaid and Commercial payers tend to focus on chronic care conditions Can be prospective or retrospective Most bundling is retrospective, which requires no change to billing systems Can have varying episode lengths (e.g., 30, 60, 90 days, annual) Often factor out unrelated conditions and have ways to mitigate risk HDG 2016 5 2016 Health Dimensions Group 3
Medicare Alternative Payment Methods: Bundling Is a Category 3 APM Category 1 Fee for Service No Link to Quality & Value Category 2 Fee for Service Link to Quality & Value Category 3 APMs Built on Fee-for- Service Architecture Category 4 Population- Based Payment Payments based on volume of services; not linked to quality or efficiency At least a portion of payments vary based on quality or efficiency of health care delivery Some payment linked to effective management of a segment of the population or an episode of care; payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment not directly triggered by service delivery so payment not linked to volume; clinicians and organizations are paid and responsible for care of a beneficiary for a long period (e.g., 1 year) Source: Alternative Payment Model (APM) Framework Final White Paper, Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group, Health Care Payment Learning & Action Network, Public Release Version 1/12/2016 HDG 2016 6 2022 Goal: Minimum of 50% of Medicare Post-Acute Provider Payments Bundled Billions $40 $35 $30 $25 $20 $15 $10 $5 Reduce Spend by -2.85% $0 2013 2015 2016 2018 2020 2022 BPCI Voluntary Pilot Began Second Round of BPCI Mandatory Geographic Ortho Bundling All Post-acute Care Providers Source: Budget of the United States Government, FY 2016; http://www.whitehouse.gov/omb/budget HDG 2016 7 2016 Health Dimensions Group 4
NYS VBP Roadmap Anticipates Both Acute and Chronic Bundles Acute (e.g., maternity care, stroke) Managed care organizations (MCOs) will contract for patient-focused episodes of care with groups of providers (or PPSs) Cost of a patient s office visits, tests, treatments and hospitalizations associated with a specific illness or medical event, or condition are all rolled or bundled into a single episode Chronic (e.g., bipolar, hemophilia, depression) According to the Roadmap, NYS will follow internationally emerging best practices to treat chronic conditions as full-year-of-care bundles, emphasizing the continuous nature of this care, including all related care to the chronic condition HDG 2016 8 Medicare Bundling Fundamentals Bundled Payments for Care Improvement (BPCI) HDG 2016 2016 Health Dimensions Group 5
Medicare Bundled Payments for Care Improvement (BPCI) Initiative Types of Services Included in Bundle Model 1 Acute Hospital Stay Only Model 2 Acute Hospital + Post-Acute Model 3 Post-Acute Care Only Model 4 Acute Hospital + Readmissions Inpatient hospital and physician services Related post-acute care services Related readmissions Other services defined in bundle (Medicare Part A & Part B) Target to performance payment Retrospective Retrospective Retrospective Prospective Number of NY participants 42 10 Established as 3-year, voluntary demonstration program by Center for Medicare & Medicaid Innovation (CMMI) HDG 2016 10 Bundled Payments for Care Improvement (BPCI): Episode Triggered by Hospitalization Clinical episodes are selected from one of 48 possible diagnostic categories (MS-DRGs) Episodes are 30, 60, or 90 days in length and commence with episode initiating anchor hospitalization Base period target price (less 2% 3% discount) compared to performance period expenditures on apples-to-apples basis about six months after the episode is over Anchor Hospitalization Model 2 Post-Acute Care Model 3 End of Episode (30, 60, 90 days) HDG 2016 11 2016 Health Dimensions Group 6
In Retrospective BPCI Models (1, 2, 3), No Money Changes Hands Upfront All providers are paid through regular fee-for-service (FFS) rules and coverage criteria Bundling is retrospective calculation where actual FFS expenditures for each quarterly performance period are compared to target prices with an upfront discount HDG 2016 12 Bundlers Were Required to Select Diagnostic Families by October 1, 2015 (48 Possible) Diagnostic Families (aka Clinical Episodes) Percentage of Model 2 (Hospital/PGP) Bundlers Selected Episode Percentage of Model 3 (Post-Acute/PGP) Bundlers Selected Episode Major joint replacement of the lower extremity 68% 58% Congestive heart failure 35% 41% Simple pneumonia and respiratory infections Chronic obstructive pulmonary disease, bronchitis, asthma Hip and femur procedures except major joint 34% 47% 32% 39% 27% 36% Top 5 DRG Groups Are Bundled by Both Acute Model 2 and Post-Acute Model 3 Source: CMS Analytic File, October 13, 2015; CMS BPCI newsletter November 2015, Ed. 7 HDG 2016 13 2016 Health Dimensions Group 7
BPCI Is for FFS Patients Only: Triggered by Anchor Hospitalization Beneficiary must be eligible for Part A and be enrolled in Part B Beneficiary must not: Qualify for Medicare solely through ESRD Be enrolled in any managed care plan Beneficiary must have had an applicable anchor inpatient hospital admission Beneficiaries must be informed about bundling and may opt out of care redesign activities, but will still be included in bundling reconciliations if otherwise eligible HDG 2016 14 What s Included and Excluded in Target Price Is Very Important Target prices contain exclusions for: Unrelated conditions to bundle diagnosis (e.g., cancer diagnosis) Part D drugs Hospice claims Hospice services are not included in BPCI, but advance care planning, palliative care, and hospice services can be important elements of care redesign HDG 2016 15 2016 Health Dimensions Group 8
Target Price Based on Bundler s Own Historical Experience Each bundler s episodic target prices for a diagnostic family derived from their own episodic experience from July 1, 2009, to June 30, 2012: Episodes with low volumes are based on statewide averages, in whole or in part Target prices are inflated to performance period by trend factors based on national average growth rates that reflect changes in prices and care practices Differences in wages over time are factored in to target prices Target prices are discounted by 2% to 3% depending on model type and episode length Use of national average growth rates to inflate target prices means that even favorable prices may erode over time, rewarding early adopters HDG 2016 16 Target Price Compared to Expenditures in the Performance Period Reconciliations are quarterly and start 6 months after end of episode; adjusted up to 3 additional quarters as additional claims filed Target Price Quarter 1, Patient 1 Quarter 1, Patient 2 Quarter 1 Total Reconciliation $19,000 (base period costs) less CMS 3% discount Actual fee-for-service spending during episode Amount to be paid back to CMS at reconciliation Actual fee-for-service spending during episode Amount of gain to bundler at reconciliation Net amount to be gained by/(paid back from) bundler $18,400 $20,000 ($1,600) $15,000 $3,400 $1,800 HDG 2016 17 2016 Health Dimensions Group 9
Second Application Period Grew BPCI Significantly 2013 2015 214 organizations 1,618 organizations Episode Initiators by Provider Type 723 SNFs 415 Hospitals 305 Physician groups 103 HHAs CMS has indicated that another round of bundling is possible after evaluation of current participants 9 IRFs 1 LTCH Source: CMS BPCI newsletter November 2015, Ed. 7 HDG 2016 18 At-Risk Bundlers in NYS: 42 Model 2 (13 PGPs) Organization Name # City Albany Memorial Hospital 4 Albany St. Peter's Hospital 3 Albany Southside Hospital 2 Bay Shore United Health Services Hospitals 18 Binghamton Montefiore Medical Center 2 Bronx NYU Lutheran Medical Center 1 Brooklyn The Brooklyn Hospital Center 18 Brooklyn Buffalo General Medical Center 6 Buffalo Corning Hospital 4 Corning Arnot Ogden Medical Center 2 Elmira Flushing Hospital Medical Center 22 Flushing Huntington Hospital 1 Huntington Jamaica Hospital Medical Center 20 Jamaica North Shore University Hospital (Nsuh) 2 Manhasset Winthrop-University Hospital 1 Mineola Long Island Jewish Hospital 1 New Hydepark Hospital for Special Surgery 1 New York Lenox Hill Hospital 3 New York Mount Sinai Roosevelt Hospital 2 New York New York University Hospitals Center 3 New York The Mount Sinai Hospital 4 New York South Nassau Communities Hospital 1 Oceanside Canton-Potsdam Hospital 2 Potsdam Highland Hospital 2 Rochester Strong Memorial Hospital 1 Rochester St. Joseph's Hospital Health Center 2 Syracuse Samaritan Hospital 4 Troy Seton Health (St. Mary's Hospital) 6 Troy Saint Anthony Community Hospital 1 Warwick PGP Organization Name # City Rockland Orthopedics & Sports Medicine 1 Airmont Orthopedicsny, LLP 1 Albany Exigence Hospitalist Medical Services of Hornell, PLLC 7 Amherst UHS - United Health Services Medical Group 17 Binghamton Syracuse Orthopedic Specialists, PC 5 East Syracuse Exigence Hospitalist Medical Services of Lewiston, PLLC 35 Lewiston Advanced Orthopedics & Sports Medicine, PLLC 1 Nanuet Northeast Orthopedic & Sports Medicine, PLLC 1 Nanuet Premier Orthopaedics of Westchester & Rockland 1 New City Orangetown Orthopedic Associates 1 Orangeburg St Joseph's Physician Health PC 18 Syracuse St. Joseph s Medical PC 1 Syracuse Clarkstown Orthopedics 1 West Nyack # = Number of diagnostic categories at risk HDG 2016 19 2016 Health Dimensions Group 10
At-Risk Bundlers in NYS: 10 Model 3 (1 PGP) Organization Name # City Visiting Nurse Service of New York Home Care 2 New York Village Center for Care 13 New York Parker Jewish Institute for Health Care and Rehabilitation (SNF) 6 New Hyde Park Parker Jewish Institute for Health Care And Rehabilitation (CHHA) 6 Lake Success UHS - Twin Tier Home Health Care - Vestal 1 Binghamton UHS - United Health Services Medical Group 2 Binghamton Belair Nursing & Rehabilitation Center 13 Bellmore Huntington Hills Center for Health & Rehabilitation 11 Melville The Pines at Poughkeepsie Center for Nursing & Rehabilitation 3 Poughkeepsie Sands Point Center for Health & Rehabilitation 1 Port Washington PGP Organization Name # City UHS - United Health Services Medical Group 2 Binghamton # = Number of diagnostic categories at risk HDG 2016 20 Roles for Post-acute in Model 2 & 3 BPCI: Vendor or EIP Until Another Round of BPCI Permitted Model 2 Episode Integrated Provider to Model 2 hospital or physician group practice (PGP), preferably with gainsharing Preferred Vendor to Model 2 hospital or PGP by accepting referrals and effectively managing care Model 3 BPCI Awardee (accept risk, control gains) Episode Integrated Provider to Model 3 Awardee (e.g., SNF or HHA to Model 3 PGP) Preferred Vendor to Model 3 PGP or PAC (e.g., HHA to SNF) HDG 2016 21 2016 Health Dimensions Group 11
BPCI Has Features to Address Risk & Multiple Bundlers in Same market Risk (and opportunity) can be mitigated for bundlers by the selection of moreconservative risk tracks and through the outlier mechanism When multiple bundlers are operating in the same market for the same diagnostic categories, CMS has precedence rules to determine pecking order CMS Precedence Rules HDG 2016 22 Gainsharing in Bundling Context: Expansion Will Take Time Gainsharing in a bundling context is executed through waivers and may become more widespread as bundling grows Policy on gainsharing is rapidly evolving as alternate payment approaches flourish In general, gainsharing arrangements must: Have strong quality component, preferably using evidence-based guidelines Not be created to directly or indirectly induce referrals Not harm the beneficiary October 3, 2014 Federal Register HDG 2016 23 2016 Health Dimensions Group 12
Waivers Under Bundling May Offer Opportunities for Post-acute Providers Modification of 3-day qualifying stay for Medicare SNF Allows SNF coverage for 1-day or 2-day prior acute stay for Model 2 bundlers Post-discharge home visits Allows billable visits monthly throughout episode which can be delegated by physicians to other clinicians Telehealth Waives geographic restrictions on telehealth providing that all other Medicare coverage requirements apply HDG 2016 24 Early Results: Bundling Will Change Post-acute Care Utilization First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF, LTACH, IRF) fell by 30%; use of HHA stayed about the same* Recent letter to JAMA about NYU s Model 2 BPCI program shows 49% and 34% reductions in discharges to institutional PAC for cardiac valve and joint replacement episodes, respectively Two mature joint replacement bundling programs show 40% 50% drop in discharges to SNFs and corresponding increases to home with outpatient therapy or home health Caution: Early results are heavily influenced by ortho bundles and possible selection bias; nonetheless, the results and our experience indicates that bundling can drive market shifts *Source: CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation & Monitoring Annual Report, The Lewin Group, February 2015 HDG 2016 25 2016 Health Dimensions Group 13
Comprehensive Care for Joint Replacement Model (CJR) HDG 2016 New CMS Bundling Program: Comprehensive Care for Joint Replacement (CJR) Finalized for April 1, 2016, implementation Mandatory Program Hospitals Bear Financial Risk First mandatory demonstration, requiring participation from all hospitals in 67 metropolitan regions Hospitals must bear risk for hospital care and 90 days post-discharge for MS-DRGs 469 and 470 (major lower joint replacement) CJR Mandatory Locations Shared Savings Directly Tied to Quality Measures To qualify for realized savings, hospitals must meet specified quality measure performance targets Source: https://innovation.cms.gov/initiatives/cjr HDG 2016 27 2016 Health Dimensions Group 14
Two CJR Regions in NYS New York-Newark- Jersey City, NY-NJ-PA Buffalo-Cheektowaga- Niagara Falls, NY 70 Hospitals in NY portion of MSA 8 Hospitals HDG 2016 28 Comparison Between Model 2 BPCI and CJR Domain Model 2 BPCI CJR Participation Voluntary Mandatory Scope Up to 48 MS-DRG families Length of bundle 30, 60, or 90 days Target price Own historical data (2009 2012 trended) Joint replacement only (MS-DRGs 469 & 470) 90 days Reconciliation Quarterly Annual Phase-in to trended regional prices Gainsharing Allowed under waivers Allowed under waivers Hospice Excluded Included Three-day SNF waiver Majority of SNFs must be rated 3 stars or higher SNFs must be rated 3 stars or higher HDG 2016 29 2016 Health Dimensions Group 15
Included and Excluded Services in CJR Included Services Physicians services Inpatient hospitalization Inpatient hospital readmission Inpatient psychiatric facility (IPF) Long-term care hospital (LTCH) Inpatient rehabilitation facility (IRF) Skilled nursing facility (SNF) Home health agency (HHA) Hospital outpatient services Outpatient therapy Clinical laboratory Durable medical equipment (DME) Part B drugs and biologicals Hospice PBPM payments under models tested under section 1115A of the Social Security Act Excluded Services Acute clinical conditions not arising from existing episoderelated chronic clinical conditions or complications of the LEJR surgery Chronic conditions that are generally not affected by the LEJR procedure or postsurgical care List of excluded MS-DRGs and ICD-CM diagnosis codes, including both ICD-9-CM and ICD-10-CM, is posted on CMS website HDG 2016 30 Direct Linkage of Payment to Quality Accomplished through creation of composite quality score, based on measure encompassing both joint replacement complications and patient satisfaction Gains limited to only those hospitals that achieve minimum composite quality scores Additional incentive payments available for those hospitals with higher composite quality scores HDG 2016 31 2016 Health Dimensions Group 16
CJR Collaborators Provides an Updated View About Risk Sharing CMS and the OIG created this concept to facilitate sharing of risk between hospitals and other providers through a process that waives the application of fraud, waste & abuse laws CJR collaborators must be Medicare providers participating in the care redesign and can share both up- and down-side risk (as well as internally derived cost savings) up to certain limits This change is the next step in recognizing that value-based payment transformation requires more flexible application of fraud, waste & abuse laws that inhibit care redesign HDG 2016 32 First Setting After Joint Replacement Demonstrates Opportunities/Threats Medicare Spending for 90-day Episodes by First Setting after Hospitalization $90,000 $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 Joint Replacement with Comorbidity (DRG 469) Joint Replacement without Comorbidity (DRG 470) Source: Dobson DaVanzo analysis of Medicare Limited Data Set, 2011 2013 HDG 2016 33 2016 Health Dimensions Group 17
First Setting After Joint Replacement: Volumes Vary by DRG and First Setting First Post-acute Setting After Joint Replacement Joint Replacement with Comorbidity (DRG 469) Joint Replacement without Comorbidity (DRG 470) Both DRG 469 & 470 Setting Count 90-day Episode Spending Count 90-day Episode Spending Count 90-day Episode Spending Community 556 $25,429 34,626 $16,172 35,182 $16,318 HHA 2,129 $28,297 104,208 $19,610 106,337 $19,784 Hospice 8 $41,490 28 $29,460 36 $32,133 IRF 2,656 $54,053 26,317 $36,351 28,973 $37,974 LTCH 158 $85,417 115 $49,891 273 $70,452 Other Inpatient 28 $48,485 200 $29,475 228 $31,809 SNF 8,321 $50,248 104,362 $31,131 112,683 $32,543 Readmission 344 $50,795 4,823 $29,493 5,167 $30,911 Total/Average 14,200 $47,093 274,679 $25,352 288,879 $26,421 Source: Dobson DaVanzo analysis of 90-day joint replacement episodes from Medicare Limited Data Set for 2013 HDG 2016 34 Joint Replacement Episode Costs Can Vary by Many Factors Total Episode Spending by Type of Surgery, Age, Gender, and Comorbidities Source: American Hospital Association Comment Letter to CMS, CCJR Proposed Rule, September 8, 2015 HDG 2016 35 2016 Health Dimensions Group 18
CJR Will Likely Drive Care to Lower Cost Settings Especially for Elective Hip and Knee Replacements SNF & IRF Care Home Health Outpatient Therapy HDG 2016 36 Cleveland Clinic Model 2 BPCI Results for Major Joint Lower Extremity Cleveland Clinic s Experience Under Model 2 BPCI for Major Joint Lower Extremity Baseline Data Euclid Hospital Results Year 2013 2013 2014 Quarter Q1 Q4 Q1 Q2 Q3 Medicare A/B Patients* 72* 65 61 66 79 Cauti Rate* 5.2 0 0 0 0 LOS* 3.40 2.90 2.67 2.87 3.01 Readmission* 5.0% 2.0% 1.6% 2.7% 2.0% Discharge Disposition Home/HHC* 39% 71% 75% 70% 68% Discharge Disposition SNF* 56% 28% 25% 30% 31% HCAHPS Overall Rating* 73% 88% 78% 84% 85% Sources: * Cleveland Clinic; 2014 Q3 CMS Reconciliation Report 2058-002 HDG 2016 37 2016 Health Dimensions Group 19
Montefiore s Model 2 BPCI Results for Major Joint Replacement Are Similar Goals: Increase discharges to home Decrease hospital length of stay Improve pre-operative care Achieve functional outcome quicker How did they do it? Program Initiation Through tight relationship with hospital-owned HHA, developed clinical protocols and education for staff, aides, patients, and families Developed relationship with SNF with 7 day/week access to physicians, trained staff, and customer-friendly facility Source: Ehrlich, Developing an Elective Joint Replacement Program, 2015 HDG 2016 38 Multiple Medicare VBP Programs Can Operate at the Same Time HDG 2016 39 2016 Health Dimensions Group 20
Interplay Between BPCI & CJR for Joint Replacement Episodes Is Complicated Hospitals in Model 1, 2, or 4 BPCI and at risk for joint replacement are NOT required to participate in CJR (unless they drop joint episodes from BPCI) Physician group practices (PGPs) and post-acute providers at risk in Model 3 BPCI for joint replacement episodes will TAKE PRECEDENCE over CJR HDG 2016 40 Bundlers and ACOs May Work Together Medicare Accountable Care Organizations (ACOs) are growing significantly CMS permits a beneficiary to be in bundling and an ACO at the same time Policy is to only pay once for savings, so CMS will recoup a portion (e.g., 50%) of upfront target price discount (2-3%) from the bundler for each overlapping bundled patient also enrolled in an ACO that has achieved its savings target Since bundlers can be instrumental in helping ACOs achieve their savings targets, this recovery should not dissuade bundlers and ACOs from developing win-win relationships HDG 2016 41 2016 Health Dimensions Group 21
Bundling for a Medicaid Population Acute & Chronic Care Bundling Is on the Menu in NY VBP Roadmap Options Level 0 VBP Level 1 VBP Level 2 VBP Level 3 VBP Acute and chronic bundles FFS with bonus and/or withhold based on quality scores FFS with upside-only shared savings based on bundle of care (savings available when outcome scores sufficient) FFS with risk sharing based on bundle of care (upside available when outcome scores sufficient; downside reduced when outcome scores are high) Prospective bundled payment (with outcome-based component) HDG 2016 Tennessee s (TN) Bundling Program: Medicaid Aligned with State Health Plan Source: Tennessee Division of Health Care Finance & Administration, Health Care Innovation Initiative, Health Care Payment Learning and Action Network Summit, October 26, 2015 HDG 2016 43 2016 Health Dimensions Group 22
TN Bundling Creates Episodes: Ranks Providers from High to Low Source: Tennessee Division of Health Care Finance & Administration, Health Care Innovation Initiative, Health Care Payment Learning and Action Network Summit, October 26, 2015 HDG 2016 44 TN Has Plans to Add Episode Dx Types: Up to 50% of Medicaid to Be Bundled Source: Tennessee Division of Health Care Finance & Administration, Health Care Innovation Initiative, Health Care Payment Learning and Action Network Summit, October 26, 2015 HDG 2016 45 2016 Health Dimensions Group 23
Arkansas Has 16 Bundles Underway: Medicaid Aligned with Commercial Payers Source: http://www.paymentinitiative.org/episodesofcare/pages/default.aspx, accessed January 19, 2016 HDG 2016 46 NY VBP Roadmap Plan for Bundling: Evidence-informed Case Rates (ECR) Roadmap states that for care bundles, the most recent version of the open source Evidence-informed Case Rate (ECR ) riskadjustment methodology will be used, developed by the nonprofit Health Care Incentives Improvement Institute (HCI3) ECR is an entire episode of care definition that includes all covered services across all providers that would typically treat a patient for a single illness or condition (hospital, physicians, laboratory, pharmacy, rehabilitation facility, etc.) HCI3 s ECRs are open source definitions that can be used for multiple purposes, including bundled payment and cost/quality analysis of providers www.hci3.org Source: Prometheus Evidence-informed Case Rate (ECR) Contracting Strategies and Guidelines for Health Plans, Health Care Incentives Improvement Institute, Inc., March 2011 HDG 2016 47 2016 Health Dimensions Group 24
ECR Has Relatively Sophisticated Method to Analyze Claims Data ECRs have careful definition of episode trigger, depending on whether acute or chronic episode 80 ECRs currently developed Risk-adjusted budgets are created in provisional (baseline) period Claims in performance period are categorized into Potentially Avoidable Complications (PAC) and Typical Costs for development of quality goals and shared savings targets Unrelated care to episode excluded by clinical and empirical rules Flexible model that can accommodate L1, L2, or L3 VBP Source: Prometheus Evidence-informed Case Rate (ECR) Contracting Strategies and Guidelines for Health Plans, Health Care Incentives Improvement Institute, Inc., March 2011 HDG 2016 48 ECR Could Eventually Be Applied to MLTC Population for Chronic Episodes Annual chronic care episodes for community-based enrollees in MLTC plans Bundle could include: CHHA, personal care, transportation, adult day, nursing home placement Ultimately could include Medicare-covered costs for duals (when Medicare shares data with NY) Annual performance periods with specified triggers Episodes could be risk-adjusted by Uniform Assessment Instrument data to incorporate activities of daily living (ADLs), comorbidities, and social factors Source: Hypothetical example by author HDG 2016 49 2016 Health Dimensions Group 25
Strategies for Bundling Success Care Redesign and Approaching Payers with Value Proposition HDG 2016 Transforming Care. Takes Thoughtful Orchestration HDG 2016 51 2016 Health Dimensions Group 26
Bundlers Assume Risk for Outcomes Over a Episode: Across Settings Care Redesign Strategies Transitions management: Between acute care and post-acute to community settings Coordination with primary care Coordination with specialty care Risk stratification Patient activation, teaching, and self-care Medication reconciliation at every transition Primary care engagement Utilization of telehealth HDG 2016 52 In Your Own Bundle or Someone Else s Performance Matters Data E.g., length of stay, costs, readmissions rates, costs (by key diagnosis) Quality E.g., patient safety (wounds, falls, infections), patient satisfaction; star ratings Process E.g., care transitions, care pathways, INTERACT HDG 2016 53 2016 Health Dimensions Group 27
Risk Stratification and Resource Allocation Segment patients into care groups with similar needs, trajectories, and utilization patterns Utilize established care strategies with person-centered interventions Allocate resources to patients at increased risk of an adverse health outcome or worsening health status Stable Rising Risk High Risk Goal: Support Goal: Early Intervention Goal: Stabilize HDG 2016 54 Roughly 40% of All Medical Spending Precipitated by Unmet Social Support Needs Low literacy Language barriers Poor nutrition Unsafe housing Family violence Mental illness Lack of support for overwhelmed, exhausted family caregivers Source: Addressing Patients Social Needs. Bachrach, Pfister, Wallis, and Lipson, Manatt Health Solutions, May 2014 HDG 2016 55 2016 Health Dimensions Group 28
Telehealth: An Expanding Strategy in Bundling OIG waivers allow bundlers to provide beneficiary with incentivizing services and equipment during the episode if related to care redesign Telemonitoring Passive ADL monitoring Personal safety devices Videoconferencing HDG 2016 56 Four Key Elements to Transforming Care Robust care redesign that targets avoidable hospitalizations in all settings and transitions Know outcomes and costs by diagnosis category Prepare the patient and family for the next level of care and get them there as quickly as safely possible Risk stratify using data analysis and customizing intensity of interventions HDG 2016 57 2016 Health Dimensions Group 29
Bundling Requires Managing in the Gray Zones Medical crisis requiring acute care intervention or stabilization Return to stabilized state or death Continued care for rehabilitation or palliative care Health care reform through new payment models emphasizes (providers ) role in making decisions in the gray zone, but it s not known how well (providers) will respond to this challenge or what incentives will elicit the best response. Source: Chandra, Khullar, and Lee, New England Journal of Medicine, 372;3 nejm.org January 15, 2015 HDG 2016 58 HDG 2016 59 2016 Health Dimensions Group 30
Value-Based Payment Webinar Series Webinar 1 December 16, 2015 What Means to Providers Webinar 2 Bundling as a Platform for Understanding VBP Webinar 3 March 1, 2016 New Models of Care Under Webinar 4 March 23, 2016 Understanding Risk in a Value-Based World HDG 2016 60 Thank You! Any Additional Questions? HDG 2016 2016 Health Dimensions Group 31
HDG s Experience With Bundling HDG has assisted health care systems representing over 75 episode-initiating providers with participation in Medicare s Bundled Payments for Care Improvement (BPCI) initiative, supporting 3 of the 10 largest private Model 3 conveners Along with our data partner, Dobson DaVanzo, HDG provides consulting and analysis for providers to self-convene (directly take risk) or to participate with other conveners, by: Interpreting CMS policies Analyzing Medicare claims data Consulting on care redesign Advising on optimal strategy HDG 2016 62 Health Dimensions Group: What We Do Strategic Consulting Strategic planning and positioning Health care continuum alignments Market growth strategies PACE development Bundling implementation Senior service line development Post-acute medicine development Operational and Performance Improvement Clinical Financial and billing Regulatory compliance Reimbursement advisory Transaction advisory Business office support Operations reengineering Management Solutions Strategic planning and positioning Turnaround management Transitional leadership Full-service management Acquisitions and divestiture Interim management HDG 2016 63 2016 Health Dimensions Group 32
For More Information Brian Ellsworth, MA Director, Payment Transformation Health Dimensions Group 860.874.6169 cell bellsworth@hdgi1.com Beth Carlson, EdD, RN, NHA Director, Consulting Services Health Dimensions Group 763.201.1985 612.723.1779 cell bethc@hdgi1.com www.healthdimensionsgroup.com @HDGConsulting https://www.facebook.com/healthdimensionsgroup http://www.linkedin.com/company/health-dimensions-group HDG 2016 64 Presentation Title HDG 2016 65 2016 Health Dimensions Group 33