90 days to bundled payments: roadmap and methodology for implementing your bundled payments...

90 Days to Bundled Payments

May 28, 2015

[email protected]

(248) 613-7166

Sheldon Hamburger

mailto:[email protected]

Background

Today’s presentation

• Case study(ies)

• Lessons learned

• You’re the payer • Executive leadership is essential

• Opportunity tends to be in post-acute

• Doing the right thing is most profitable

Today

PAC

30%

DRG

70% PAYER

Bundled Programs

PAC

70%

DRG+Savings

30% PAYER

The Future

PAC

100%

New DRG

PAYER

Anchor Stay 44%

Ambulatory 4%

HHA 5%

Readmissions

13%

IRF 9%

LTAC 4%

Other 2%

SNF 18%

Sample Hospital

Total Program 100% $113,000,000

Anchor Stay 44% $50,000,000

Post-Acute 56% $63,000,000

Ambulatory 4% $5,000,000

HHA 5% $6,000,000

Readmissions 13% $15,000,000

IRF 9% $10,000,000

LTAC 4% $5,000,000

Other 2% $2,000,000

SNF 18% $20,000,000

Agenda

0-30 30-60 60-90 Tactical Planning

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment Convener Selection

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment Convener Selection Bundle Selection

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment Convener Selection Bundle Selection (CMS) Contract Process

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment Convener Selection Bundle Selection (CMS) Contract Process Post-Acute Care Design

Agenda

0-30 30-60 60-90 Tactical Planning Organizational Alignment Convener Selection Bundle Selection (CMS) Contract Process Post-Acute Care Design Performance Metrics

Tactical Planning

Planning components

• Formalized plan

• Team approach

• Project management

• Managing competing priorities

Tactical Planning

Formalized plan

• Use of formal methodologies

• Use existing standards where available

• Sample tools such as: – Project plan

– Regular status report

– Issue log

• Regular communication is essential

• Plan maintenance is a key success factor

Tactical Planning

Organizational structure

• Dedicated operational teams

• Multidisciplinary team:

– Clinical

– Legal

– IT

– Finance

• Requires oversight/governance

Governance Team Chair:

Members:

Frequency:

Charter:

Care Coordination Team

Chair:

Members:

Frequency:

Charter:

Bundle Integration Team

Chair:

Members:

Frequency:

Charter:

Gainsharing Team

Chair:

Members:

Frequency:

Charter:

Team Definitions

GENERIC ROLES

COO - Chief Operating Officer for the program

CFO - Chief Financial Officer for the program

CMO - Chief Medical Officer for the program

CNO - Chief Nursing Officer for the program

CIO - Chief Information Officer for the program

CQO - Chief Quality Officer for the program

CCCO - Chief Care Coordination Officer for the program

CCO - Chief Compliance Officer for the program

Governance Team

Key Activities

• Program oversight

• Strategy and planning

• Decision making

• Direction

• Leadership

• Compliance

• Ultimate program responsibility

Note: Meet monthly - Communication critical

Care Coordination Team

Key Activities

• Care coordination metrics

• Staffing – Care Navigator

• Care transition policies & process

• Education – program rules & care transitions

• Risk stratification

Bundle Integration Team

Key Activities

• Bundle metrics

• Staffing

• Update/standardize care protocols/pathways

• Bundle-related documentation (patient/provider)

• Program education strategy

• Risk stratification

Gainsharing Team

Key Activities

• Define gainsharing terms

• Decision making / oversight

• Fund distribution

• Entity / Professional eligibility

Note: Ad-hoc meetings until distribution begins.

Quarterly thereafter.

Tactical planning

Project Management

• Importance of dedicated project manager (PM) – Provide day to day leadership and focus

– Ensure progress toward success

• PM roles/responsibilities – Maintains the structure and processes

– Tracks budgets and scope

– Coordinates resources

– Ensures that a quality program is delivered

Tactical Planning

Managing competing priorities

• “I already have a job” • Support from highest levels of organization

• Shift priorities / delegate work

• Reliance on teams

Tactical Planning

How we did it

• Full team kickoff meeting

• Immediate team assignments

• Immediate team meetings

– Action driven

– Structured reporting

• Immediate work initiation

• External PM

Agenda


Organizational Alignment

Leadership from the top

• This is wholesale change to thinking

• Organizational commitment

– Across all departments/disciplines

• Culture shift

• Continuous focus on “getting it right”


Managing change

• Clear, consistent messaging

• Set realistic expectations / timelines

• Phased approach

• Identify problems early

• Enforcing accountability


Education

• Leadership

• Surgeons

• Clinical staff

• Case management/social work

• Post-acute provider providers – Preferred and non-preferred

• Patient

Note: Start early and educate continuously


Systems/methods

• Leverage existing resources

– Video/intranet/classroom

• Marketing

– Copy and production

• Materials

– Presentations, white papers, news items

• Industry conferences

– Financial, clinical, topical


Leadership education • Kickoff meeting

• Governance meeting

• Peer to peer

Surgeon education • Surgeon champion(s)

• Part of leadership team

• Ad-hoc meetings with other surgeons

• Financial models


Clinical Education

• Service line managers

• Care coordination team managers

• Part of leadership team

• Train the trainer approach


Post-acute provider education

• Begins with network development

• Continues through selection/rejection

• Group and individual meetings

• Preferred and non-preferred providers


Patient education

• Consistent messaging from everyone

– Physicians

– Program sponsors and employers

• Emphasis on quality and care coordination

• Pre-admission through end of episode

• Collateral: handouts, wall-charts, multi-lingual


How we did it:

• Start early

• Leverage existing capabilities

• Re-purpose existing materials

• Include all levels of organization

• Sell the message

Agenda


Convener Selection

The role of the convener

• BPCI specific role

• CMS general contractor

• Not required

• May/may not bear risk

• Generally bring a data partner

• Aggregate awardees (like you) to share lessons

• Source of information/strength vis-à-vis CMS

Convener

Convener Selection

Do I need a convener?

Yes No

Leverage their experience Have dedicated resources

“Ready-to-go” Contract with data partner

Shared lessons learned Experienced in value-based

Bring resources Save the money

Convener Selection

Changing your convener

• Allowable

• No time for selection process

• Big issue: delay in getting data

• Immediate issue: paperwork/processing time

• BPID, DUA, EFT

Convener Selection

How we did it

• Planning (including Plan B)

• Set expectations within the organization

• Push, push, push

• Constant attention to every step

Agenda


Bundle Selection

Key drivers for your strategy

• Institution specific

– Your areas of specialization

• Geographic specific

– Patient demographics

• Payer specific

– What’s in/out?

– Pricing benchmarks

Bundle Selection

Key drivers for your strategy

• Availability of data

– Internal and payer systems

– Experiential

• It’s all about post-acute spend

• Ability to drive/driven positive change

• Volume creates leverage

• General spend trend line for the bundle

• Understanding of post-acute environment

Bundle Selection

Key data points for your selection

• Overall episode volume by DRG, surgeon, etc.

• Distribution of spend within an episode

– Average, over time, by setting, per episode

• Trend in quarterly average spend

• Readmissions: rates and reasons

• Episode duration (30, 60, 90)

• Risk track selection (BPCI)

Bundle Selection

Bundle # Avg.

Spend Anchor LTCH

IP

Rehab SNF

Home

Health Readmits OP Part B DME

Major Lower Joint 12 29.5K 40% 0% 0% 20% 8% 5% 9% 17% 0%

Bundle #Avg.

SpendMin Max Benchmark

Major Lower Joint 76 43.1K 16.6K 90.7K 45.9K

Bundle Selection

HHA 9%

Readmits Part B 17%

14%

150 Episodes $22.6K Avg. Spend

Anchor 27% SNF 26%

IRF 1% DME 2%

Congestive Heart FailureSpending by site

OP 4%

Bundle Selection

Congestive Heart Failure

159 Episodes

21.6K Average Cost (18.3K-24.9K)

Bundle Selection

Bundle Selection

What if I don’t have my payer data?

• Internal and experiential data

– Volumes by DRG, surgeon, setting

– Readmissions

• Review process changes in past several years

– Readmissions

• Drivers of positive results that effect post-acute

– e.g., SNF referral, HHA affiliation/utilization

Agenda


(CMS) Contract Process

Key CMS contract documents

• Awardee Agreement

• Attachment B – Implementation protocol

• Attachment C – Awardee profile

• Attachment F – Gainshare List

• Attachment G – Secondary Repayment Sources

• Skilled Nursing Facility (SNF) List


Approach to the contract process

• Divide and conquer

• Legal, finance, clinical roles

• Regular, ongoing focused meeting/sessions

• Driven/coordinated by project manager

• Accountability to peers and Governance


Contract Component Responsible Team Key Issue

Awardee Agreement Legal "as is"

Implementation protocol Care Coordination, Bundle Integration, Finance, Legal

intense drill down

Awardee profile Finance risk analysis

Gainshare List Operations/Legal contracting issues

Secondary Repayment Sources (SRS)

Finance paperwork

Skilled Nursing Facility (SNF) List Care Coordination & Bundle

Integration risk analysis


Implementation protocol

• Program governance/structure

• Care redesign process

• Gainsharing/financial arrangements


Program governance/structure

• Started with template

• Team review/edits

• Oversight, gainsharing, quality issues

• Final internal consensus


Care redesign process

• Required regardless of contract !!!

• CMS defined categories

• Analyze current/future states

• Deliver final consensus and plan


Gainsharing arrangements

• Money drives behavioral change

• Who drives change? Surgeons!

• Payments must be quality based

• Negotiate quality measures/results

• Agree on financial splits


How we did it

• Start early

• Use of templates

• Assign work to teams (internal clinical resources)

• Develop sense of urgency

• Ongoing forward progress driven by deadlines

• Management negotiation with gainsharers

• Constant review and refinement

Agenda


Post-Acute Care Design

Bundles are about post-acute spend

• This is the source of your profit

• Efforts should be focused here

• Strategy is in optimizing that spend

– Direct post-acute care utilization

– Readmissions

Anchor Stay 44%

Ambulatory 4%

HHA 5%

Readmissions

13%

IRF 9%

LTAC 4%

Other 2%

SNF 18%

Total Program 100% $113,000,000

Anchor Stay 44% $50,000,000

Post-Acute 56% $63,000,000

Ambulatory 4% $5,000,000

HHA 5% $6,000,000

Readmissions 13% $15,000,000

IRF 9% $10,000,000

LTAC 4% $5,000,000

Other 2% $2,000,000

SNF 18% $20,000,000



Key post-acute partners

• SNF, HHA, IRF

• Your own ER (and other ERs)

• Community resources

• Partner’s effect is bundle specific

• Optimizing utilization is the goal


SNF # Episodes Total

Payment

Average

Payment Readmissions

Readmission

Rate

SNF 1 80 $785,461 $9,818 6 8% SNF 2 25 $301,225 $12,049 4 16% SNF 3 25 $187,522 $7,501 1 4% SNF 4 23 $354,001 $15,391 0 0% SNF 5 17 $196,222 $11,542 4 24% SNF 6 12 $164,526 $13,711 3 25% SNF 7 11 $255,124 $23,193 2 18% SNF 8 11 $91,230 $8,294 1 9% SNF 9 10 $115,235 $11,524 3 30% SNF 10 8 $152,134 $19,017 0 0% SNF 11 7 $48,256 $6,894 2 29% SNF 12 6 $44,120 $7,353 1 17% SNF 13 4 $56,125 $14,031 0 0% SNF 14 3 $14,597 $4,866 1 33% SNF 15 4 $39,256 $9,814 0 0% SNF 16 3 $13,021 $4,340 1 33%


HHA # Episodes Total

Payment

Average

Payment Readmissions

Readmission

Rate

Our own HHA 132 $422,123 $3,198 12 9%

Competitor 22 $93,213 $4,237 4 18%

Competitor 15 $87,456 $5,830 3 20%

Competitor 12 $48,213 $4,018 3 25%

Competitor 10 $35,124 $3,512 1 10%

Competitor 9 $15,784 $1,754 2 22%

Competitor 8 $23,549 $2,944 0 0%

Competitor 7 $22,056 $3,151 5 71%

Competitor 7 $18,452 $2,636 2 29%

Competitor 7 $18,547 $2,650 0 0%

Competitor 6 $18,213 $3,036 1 17%

Competitor 6 $24,153 $4,026 1 17%

Competitor 5 $17,918 $3,584 0 0%

Competitor 4 $72,123 $18,031 1 25%


Why a post-acute network? • Ensures best quality/performance

• Creates standardized/compliant care

• Develops competition toward improvement

How to create the network? • Formal selection process

• Internal input to performance metrics

• Open to everyone


Challenges • Timeframe

• Internal pushback

• External pushback

Sample performance criteria • Reduction in LOS

• Reduction in readmissions

• Adherence to our protocols/pathways


Key Activities

• RFP process

– Open to all

– Time for questions/feedback

– Scoring/evaluation process

• Partner integration

– Develop initial integration strategy/plan

– Develop integration process


How we did it

• Start with templates

• Communication from C-suite about the process

• Adherence to timeframe

• Partner integration

Agenda


Performance Metrics

Defining metrics from the start

• Can’t improve what you can’t measure

• Measure twice, cut once

• Must align with project goals

• Don’t do too much at once/from the outset

• “Dashboard” comes later

Performance Metrics

Where to begin

• Categories: financial, clinical, patient satisfaction

• What do you have today?

• Pick a limited set of new key drivers

• Questions to ask:

– Do we have it today? Where do we get it?

– Priority for launch? Who is the user?

– How often would the user need to see updates?

– How is it deployed to the user?

Performance Metrics

Data Capture • Fit in existing workflow/system

• Must measure what you want

• Requires cross functional teams

Data integration • Key identifiers (unique)

• Disparate systems

Performance Metrics

PROJECTED TARGET PRICE VS. PROJECTED SPEND = "P&L"

Facility DRG Projected

Target Projected

Spend Delta

# cases

Ext. Delta

LOC 1 DRG 1 $49,500 $55,000 ($5,500) 7 ($38,500)

LOC 1 DRG 2 $26,000 $25,800 $200 255 $51,000

LOC 2 DRG 1 $48,500 $52,000 ($3,500) 4 ($14,000)

LOC 2 DRG 2 $26,000 $23,500 $2,500 91 $227,500

357 $226,000

Bundled spend = DRG basis + post-acute proxies

SNF days x $500

HHA days x $150

Performance Metrics

Measure Description Numerator Denominator Sources of

Data Measure Period

Comparison Standard

Readmission rate (MLJ)

Overall 30 day readmission rate for MLJ patients

All readmissions to inpatient status within 30 days of

All MLJ patients EMR Quarterly <= 5.4%

DVT/PE rate DVT/PE rate for

MLJ patients

All MLJ patients with lower

extremity DVT ICD 9 code during

hospitalization

All MLJ patients QC system Quarterly <= 1.2%

Have these Negotiate these

Gainsharing

Performance Metrics

In total, by SNF, by bundle

SNF Performance Scorecard

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

# Referrals 10 12 13 8 15 11 4 7 12 12 7 9

Referral rate 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10%

Avg. LOS 9.2 8.1 11.2 15.1 10.1 11 10.4 11.2 14.1 9.4 9.2 10.1

Readmission rate 30% 33% 46% 25% 7% 45% 25% 29% 8% 42% 29% 56%

Performance Metrics

Process Metrics

Hospital Quality

Measure

Hospital Performance

Measure Program Goal

Measurement

Standard

Current

Measure

Where was Measure

Published

Association

that

compiled the

measure

How to Measure

(Numerator/

Denominator)

Medication

Management

Percentage of patients in

the hospital that had a an

assessment of medication

intake, patient and family

were counseled about their

medication, and medication

management was a part of

the patients plan of care

Improved transitions

of care and

reduction in hospital

readmissions

80%

National Transitions

of Care Collaborative-

Category 1 of 7

essential Intervention

Categories

Transition Planning

Percentage of patients in

the hospital setting that

used a formal transition

planning tool such as a

standard Transition Form

(AMDA Universal Transfer

Form) or Patient Plan of

Care tool developed in the

hospital and extended to

the SNF facility

Improved transitions

of care and

reduction in hospital

readmissions

85%

National Transitions

of Care Collaborative-

Category 2 of 7

essential Intervention

Categories

Performance Metrics

Dashboard

Performance Metrics

How we did it

• Start with existing reports

• Identified several key metrics per area – “P&L” – Bundle performance (data vendor)

– Post-acute metrics (e.g., discharge patterns to SNF)

• Manual tracking (some automation)

• Increase automation over time

Agenda


Questions ?

Sheldon Hamburger Principal

[email protected]

(248) 613-7166

mailto:[email protected]

90 days to bundled payments: roadmap and methodology for implementing your bundled payments...

Health & Medicine

planning decision

care coordination team

bundle integration team

governance team chair

gainsharing team chair

sample hospital total

new drg payer

essential plan maintenance