evaluating, developing and operating bundled payment programs · - perform scenario models -...

©2016 nThrive, Inc. All rights reserved. Confidential. RV06212016©2016 nThrive, Inc. All rights reserved. Confidential. RV06212016

Evaluating, Developing and Operating Bundled Payment Programs


WHO AM I

©2016 nThrive, Inc. All rights reserved. Confidential. RV06212016

FOUNDED:

1998FOUNDED:

2006FOUNDED:

1999FOUNDED:

1990

are now…

FOUNDED:

2016

are now…

FOUNDED:

2000


CONNECTS

all

components

of the revenue

cycle

FULLY

INTEGRATES

technology

systems ENSURES

SEAMLESS

coordination of

the financial

and clinical care

of the patient

a new kind of revenue cycle management company


5


# of

Episodes Episode Methodology Includes Examples

1Chronic Care Episode

(manages multiple chronic

conditions)

7 chronic conditions

Circulatory care episode that coordinates the care for multiple chronic

conditions, including diabetes, heart disease, hypertension, and

hyperlipidemia

1 Perinatal Episode6 MS-DRGs as episode

anchors

Pre and post-delivery services, with Vaginal Delivery or Cesarean

Section

35 Acute Care Episodes93 MS-DRGs as

episode anchorsJoint replacements, renal failure, congestive heart failure, pneumonia

21 Proprietary Episodes 21 episodes

Hip replacement, angioplasty and endoscopy; acute medical events

such as stroke, heart attack and pneumonia; chronic conditions

including diabetes, congestive heart failure, and coronary artery

disease; and pregnancy

48CMMI Bundled Payment

for Care Improvement

(BPCI) Episodes

179 MS-DRGs as

episode anchors

Congestive heart failure, pneumonia, joint replacements, diabetes,

stroke, sepsis, and UTI

1 CJR Episode4 MS-DRG Subgroups

469 and 470Joint replacements

3 EPM Episodes 3 EpisodesHeart attacks (AMI and PCI); Bypass surgery (CABG); Hip/femur

fractures (SHFFT)

109 Total Episodes

INTRO• nThrive has developed the largest number of episodes in the industry (109 episodes).

• Commercial episodes represent 40% of inpatient spend.

• nThrive’s technology also allows for the creation and management of custom episodes.

p. 5


Heart/VascularCongestive Heart Failure

(CHF) Heart Failure & Shock Hospitalization

Acute Myocardial Infarction

(AMI)

Acute Myocardial Infarction

Hospitalization (Discharged Alive)

Coronary Artery Bypass

Graft (CABG)

Coronary bypass with PTCA

Coronary bypass with cardiac

catheterization

Coronary bypass w/o cardiac

catheterization

Other cardiothoracic procedures

Cardiac Valve Replacement

Cardiac Valve Replacement with

cardiac catheterization

Cardiac Valve Replacement w/o

cardiac catheterization

Percutaneous Coronary

Angioplasty (PCI)

Percutaneous coronary angioplasty

with drug-eluting stent


with non-drug-eluting stent


without coronary artery stent

Neuroscience

Stroke

Acute ischemic stroke w use of thrombolytic

agent

Intracranial hemorrhage or cerebral infarction

Nonspecific CVA & precerebral occlusion

Orthopedic

Hip/Knee

Replacement

Major joint replacement or reattachment of

lower extremity

Bilateral or multiple major joint procs of lower

extremity

Spinal Fusion

Combined anterior/posterior spinal fusion

Spinal fus exc cerv w spinal curv/malig/infec

or 9+ fus

Spinal fusion except cervical

Cervical spinal fusion

INTRO: Designed 20 Episodes related to 8

Most Common Disease or Procedure

Conditions

p. 6


BPCI

• Target prices are set based on hospital’s historical performance only

• Price is set for each MS-DRG (e.g. 469, 470)

• Prices are not adjusted for quality outcomes

CJR

• Target prices are set on blend of hospital and regional data, transitioning to regional standard prices over 5 years period

• Price is set for the combination of MS-DRG and major risk factor (e.g. hip fracture)

• Prices are adjusted for quality outcomes

EPM

• Target prices are set on blend of hospital and regional data, transitioning to regional standard prices over 5 years period

• Additional complex episode scenarios are adjusted in pricing

• hospital-to-hospital transfer

• CABG readmissions in the AMI model

• Presence or absence of AMI in the CABG model

• Prices are adjusted for quality outcomes

INTRO: Designed Episodes for Each of

the CMS Acute Inpatient Bundles

p. 7


What Is Bundled Payment – FFS vs. FFV, fixed price, and the right accountability

Where we are as an industry with Bundled Payment

Group Interest – Where?

BPCI, CJR, EPM

Benefits (or risks from inaction):

- Potential profit

- Capture market percentage

- Increase market size

- (Example on Next Slide)

INTRO


But Complications ExistFour things thwarting value-based care: EY

1. Increasing costs of care due to inefficiency. Lack of integration across health systems and the fee-

for-service contract structure has led to inefficiencies and wasteful spending, EY notes.

2. Workforce challenges. Finding, retaining and engaging staff is an ongoing challenge — only 12

percent of respondents said clinical ancillary staff was highly engaged and 8 percent said administrative

staff was highly engaged. This can erode the patient experience and lead to burnout for nurses and

physicians, who respondents ranked as highly engaged.

3. Lack of standards to measure and define quality. Providers do not consistently measure

outcomes and quality, and sometimes do not measure them at all, according to EY. These practices

have led to inconsistencies and can put patients at risk for medical errors, according to the report. Fifty-

eight percent of respondents have initiatives underway to reduce medical errors and 18 percent have

patient safety initiatives planned for this year.

4. Poor working relationship between providers, payers and regulators. Payers and providers are

struggling to meet cost and outcomes demands in the current environment while structuring contracts to

progress toward a value-based future.

(Might I add that Poor relationships = Poor data, which you need for bundled pay management)


JUST THE LAST MONTH

An Exciting Time for Data

Systems are also being developed to

assess diabetic retinopathy (a cause of

blindness), stroke, bone fractures,

Alzheimer’s disease and other

maladies.

This year, for instance, the U.S. Food and Drug Administration approved a deep-learning approach from the start-up Arterys for visualizing blood flow in the heart; the purpose is to help diagnose heart disease.

a Stanford University

study published in January in the

journal Nature used deep neural

networks to diagnose skin cancer from

medical images. The software’s

performance was on par with 21

dermatologists, the study’s authors

wrote.

https://www.nature.com/nature/journal/v542/n7639/full/nature21056.html


Predictive Modeling in Episode of

Care

We do it for costs, readmits. Developing for more right

now.


Assess

Design

Contract

Workflow


TLDR:

- Get data and analyze the heck out of it now and in

the future (and make sure you have the skills)

- Start focusing on integration, and keep focusing


Assess

Design

Contract

Workflow


16


Assess: Vision

p. 16

Possible Reasons

- Improve Quality & Outcomes - reduce readmissions)

- Enhance revenue

- Improve the patient experience

- Patient Service Line Efficiency

- Emphasis on Accountable Care

- Maximize resources of new facilities

- Improve access across the continuum

- Growth across region or network

- Improved clinical insights

- Improve efficiency / reduce costs

- Increase workforce capability / quality

- Government mandate


17


Assess: Current State Under Episode

Model

p. 17

• How much would episode costs be currently?

• What is my service distribution across episodes?


18


Assess: Stakeholder Readiness

p. 18

- Who is for / against? Who perceives they will gain /

lose?

- Who leads…

- Innovation

- Physician Champion for bundled payment

- Quality

- Executive Sponsorship

- Oversight

- Impact of M&A?


19


Assess: Finances

p. 19

- Financial KPI’s

- Current and Possible Margin / Case

- Current and Possible Cost / Case

- Satisfaction Indices

- “Fat” removal

- Model target financial futures based on comparable bundles


20


Assess: Integration

p. 20

- How sufficiently Integrated are we?


21


Assess: Partner Performance

p. 21

- How well do our partners perform?


22


Assess: Post-Acute Alignment

p. 22

• How well-aligned is your network?

• Do you know where your patients are going?


23


Assess: Physician Performance

p. 23

• Are they performing well?

• Are they incentivized to go from FFS to FFV?


24


Assess: Risk

p. 24

• Episode Risk Profiles

• Outlier Risks

• Outlier causes

• Population Risk /

Homogeneity


25


Assess: Competitive Advantage

p. 25

- What are you good at?

- What can you control?

- Where is your high volume?


Assess

Design

Contract

Workflow


- Patient identification (trigger mechanism, etc.)

- Length of episode: Pre episode period, episode start date,

episode end date.

- Patient Exclusions

- Included and excluded services

- Principal Accountable Provider

- Core Services

- Quality Metrics

- Payment Model

Design Considerations: Formal Bundle

Definition


- Remember: More Scope =

- More Risk

- More Control

- More Potential Upside

- Scope does not necessarily equal population size

- How much chronic vs acute?

Design Considerations: Scope


Beckers Hospital: Bundled payments 101: 4 steps to develop, implement and operationalize a bundled payment strategy (Feb. 2017)

Step 1: Unlock access to your claims data

Step 2: Use claims analytics to develop your bundled payment strategy

Step 3: Collaborate transparently with your provider network

Manage your provider network with three levels of analytics:

View performance by practice and provider

Understand specific member scenarios and identify any potentially avoidable costs

Review provider benchmarking report for peer-to-peer analysis

Step 4: Operationalize your bundled payment strategies

Design Considerations: Getting at the

Data


- Do you own or manage your own health plans?

- Do you have ready access to health plan payor data? Rx data?

- Post-adjudicated?

- Are any quality initiatives in place between the health plan and the health system?

- 3rd-party data sets (Truven, etc.)

- Without this data, you’ll struggle to get very far

Design Considerations: Getting at the

Data


- Analyze possible bundle finances

- Perform scenario models

- Discover populations

- Develop risk profiles

- Report Physician and Partner Performance

- And more – all of which is helpful in understanding your

operating environment, market, capabilities, and ideal potential

bundles

Design Considerations: What to Do With

the Data


- Homogenous? Disparate?

- Remember – use your claims data to understand your

populations’ key characteristics

- Will help you define bundles that you can provide while

mitigating risks or intelligently accepting risks you can’t avoid

Design Considerations: Patient

Population


- Do you have what it takes (providers / facilities / capabilities /

etc.)

- What bundle definitions will work bet with your mix of providers,

patients, and quality initiatives?

- Would you if you worked with someone else (JV)?

Design Considerations: Organization

Capability


- In the shift to a flat-price, consumer-focused model, would

providing non-medical services round out the package?

- Gym, nutritionists, etc.

Design Considerations: Non-Medical

Services


- On cost reduction… Most of it comes from post-acute

- Lots of people reducing SNF in favor of HHA and IRF

Design Considerations: Bonus Thought


Assess

Design

Contract

Workflow


- Conditions

- Services

- materials

Contracting Considerations: Exclusions


- Procedures

- Post-Acute Treatments

- Warrantied Services (like surgery-caused issue readmits)

Contracting Considerations: Inclusions


- Drug Availability (Prescription vs Generic)

- Included physicians

- Etc.

Contracting Considerations:

Contingencies


- Employer-as-Payor

- Gainsharing

- FFS with true-up

- Withold

- Payor-defined / negotiated

- Prospective

Contracting Considerations: Payment


- Know them (Beyond the Scope of Today)

Contracting Considerations: Regulations


Assess

Design

Contract

Workflow


- Not much yet by way of standards and leading practices

- But getting care coordination together is high on the list

- Can’t communicate enough with and between groups

- Who will be the quarterback? You as the hospital.

Workflow Considerations: Overview


- Don’t automate a process until you’re comfortable with what it is

- Don’t be afraid to start things off manually

Workflow Considerations: EMR


- While EMR changes shouldn’t be undertaken too quickly,

performance tracking should

- Performance can be tracked well with the right tool

- Doesn’t require heavy implementation

- Provides significant insight into all aspects of bundle

performance

Workflow Considerations: Performance

Tracking


- Expect to run FFS and BP processes concurrently for a while

- Ultimately design one process to manage both

Workflow Considerations: Migration


- Who owns and is accountable for it? At what levels? At what

organizations?

- Don’t just train once

Workflow Considerations: Training


- Keep and eye on how you will record charges. Many ways to

lose revenue in a poorly-managed transition

Workflow Considerations: Charge

Capture

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