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The Future of Bundled Payments Kelly C. Price Vice President & Chief of Healthcare Data Analytics DataGen, a HANYS Solutions Company [email protected] February 8, 2017
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Page 1: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

The Future of Bundled Payments

Kelly C. Price Vice President & Chief of Healthcare Data Analytics

DataGen, a HANYS Solutions Company [email protected]

February 8, 2017

Page 2: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Bundled Payments for Episodes of Care

2

Average of Baseline Period: $27,650

Discount factor to incentive/ensure savings: 3%

Target: $27,650 – 3%=$26,821

A single target price for the full spectrum of services

Page 3: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Reconciliation

DRG

Performance Period Episode

Count (a)

Performance Period Episode

Target $ (b)

Total Performance

Target $ (a*b)

Total Actual Performance $

(c)

Reconciliation Amount $ ([a*b]-c)

470 w/o fracture 100 $24,000 $2,400,000 $2,200,000 $200,000

469 w/o fracture 10 $40,000 $400,000 $550,000 -$150,000

Hospital A Total 110 $24,455 $2,800,000 $2,750,000 $50,000

• First reconciliation will take place 3 months after the end of the first performance year.

• First reconciliation will be revised 12 months later to ensure all claims run-out is captured

• Same process for years 2 through 5

Page 4: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

The Evolution of Medicare Bundled Payment

ACE BPCI CJR OCM EPM

2009

Medicare Acute Care

Episode Demonstration

Program

2013

Medicare Bundled Payments for Care

Improvement Demonstration

Program

2016

Medicare Comprehensive

Care for Joint Replacements Pilot Program

2016

Medicare Oncology Care

Model Demonstration

Program

2017

Medicare Episodes of Care for PCI and CABG; Hip/Femur Fractures

Page 5: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

What’s Happening

– 2 year extension, possibility of 2.0 (MACRA) – “Education cycle” (staff change, evolving understanding, changing rules)

– Hospitals only – Mandated nature driving change in BPCI – Precedence issues – EPM rule add remaining hip/femur fractures

– Physician practices only – Risk stratification critical

– Hospitals only – Gainshare with physicians can count as Advanced APM for MIPS

Page 6: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

CJR Changes over time

Page 7: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

What’s in the baseline?

Year 1 Year 3 Year 4+

1/3

1/3

2/3

2/3

100%

Hospital

Census Region

Page 8: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

CJR 67 Mandatory MSAs

#VALUE!

Located in a Mandatory Metropolitan Statistical Area (MSA)

Analysis of Medicare Comprehensive Care for Joint Replacement (CJR) EpisodesAnywhere Medical Center

DRG 470: Major Joint Replacement or Reattachment of Lower Extremity w/o MCCWithout Hip Fracture (869 total episodes)

$0

$5,000

$10,000

$15,000

$20,000

$25,000

Anywhere Medical Center South Atlantic

Ave

rage

Ep

iso

de

Pay

me

nts

Hospital vs. Regional Benchmark Calendar Year (CY) 2014

Anchor Admission Acute Transfer Readmission Inpatient Rehabilitation

Home Health SNF Long-Term Care Hospital Inpatient Psychiatric

Hospice Physician Office DME Outpatient

# of CY 2014 Episodes *

Average CY 2014 Total Payment

Episode Component/Service Type

Average

Number of

Claims per

Episode

Average

Payment per

Episode

% of Average

Episode

Payment

Average

Number of

Claims per

Episode

Average

Payment Per

Claim

Average

Payment per

Episode

% of Average

Episode

Payment

Anchor Admission 1.0 $13,121 59% 1.0 $12,864 $12,864 62%

Acute Transfer 0.0 $0 0% 0.0 $10,761 $4 0%

Readmission 0.0 $305 1% 0.1 $7,165 $627 3%

Inpatient Rehabilitation 0.1 $813 4% 0.0 $11,908 $492 2%

Home Health 0.8 $2,052 9% 0.8 $2,691 $2,085 10%

SNF 0.7 $4,226 19% 0.6 $5,269 $3,055 15%

Long-Term Care Hospital 0.0 $0 0% 0.0 $28,658 $23 0%

Inpatient Psychiatric 0.0 $10 0% 0.0 $6,641 $11 0%

Hospice 0.0 $0 0% 0.0 $2,435 $2 0%

Physician Office 2.3 $863 4% 2.6 $318 $836 4%

Durable Medical Equipment 1.1 $124 1% 1.0 $126 $130 1%

Outpatient 2.2 $550 2% 2.2 $277 $617 3%

$5,040

$0

900 68,842

$0

$382

$13,121

$6,178

$22,063 $20,745

Average

Payment Per

Claim

$2,634

$118

Anywhere Medical Center South Atlantic

$0

$5,668

$246

$11,134

Page 9: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Cardiac Bundles 98 Mandatory MSAs

• AMI, PCI, and CABG DRGs

– Hip Fracture DRGs added to CJR

• Start date maintained as July 1, 2017

– Upside only for 2017

– Voluntary downside risk in 2018

• Target assignment very complicated

• 30 Different Target “cells”

Page 10: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Quality Performance Incentives

Rank vs. Achievement of a Threshold

Page 11: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

• Assemble the Team • Look at the data to determine your risks/opportunities • Start talking about strategies

What should you be doing right now?

Page 12: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

The Team

Analysts

Know what’s there

Don’t know why it’s there

Can’t do anything about it

Physicians

Think they know what’s there

Usually understand why it’s there

Can make things happen within their domain

Finance/Operations

Don’t know what’s there

Can make things happen throughout care

continuum

Page 13: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Look at the data Overall Patterns

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

Ep

iso

de

Pay

me

nt

Low Institutional PAC Use

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

High Institutional PAC Use

Index Admit Professional Readmission_Professional Readmission SNF HHA Outpatient DME IP Rehab LTC

Page 14: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Post-Acute Networks

• Where are you sending patients

• How do they get there

• Performance comparison

Total Number of Epiosdes: 51

Total

Episode

Count

Total Provider

Payment

Average

Prorated

Payments

ALOS Per

Episode

Total Direct

Readmissions

Direct

Readmit

Rate

SNF 26 $449,022 $17,270 36 7 27%

Nathan Willman SNF 15 $256,901 $17,127 38 3 20%

Zachary Brainard Hospital 4 $61,414 $15,353 31 0 0%

Krystal Gasnik SNF 2 $20,919 $10,459 19 0 0%

Cortny Kneefel SNF 2 $46,558 $23,279 44 1 50%

Mikkel Serocki SNF 1 $485 $485 1 1 100%

Catherine Budisavljevic SNF 1 $32,746 $32,746 62 2 200%

Brian Gough Hospital 1 $10,175 $10,175 18 0 0%

Jesse Palmer SNF 1 $19,824 $19,824 35 0 0%

Grand Total 26 $449,022 $17,270 36 7 27%

Page 15: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Detail by Surgeon

Page 16: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Real-time management vs. Strategy Review

• Real-time management

– Identify at scheduling

– Coordinate with discharge planners

– Monitor patient progress through 90 days

• Strategy Review

– What was my strategy?

– Did I follow it?

– Did it have the expected impact?

Page 17: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Performance Monitoring

Page 18: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Performance Monitoring

Page 19: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

How Does DataGen Help Providers Prepare?

• Hospitals and Physicians – Care patterns – Performance of downstream providers

• Post-Acute Providers – Referring hospitals

• Market share • Growth opportunities • Revenue loss risk

– Value statement • Average payments • Readmission rates

Page 20: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

Other Bundled Payment Webinars

• Episode Payment Model Final Rule and Analysis

– Wednesday, February 15th @ 3p EST

Registration link:

https://datagen.webex.com/datagen/onstage/g.php?MTID=eebb74d9e9096b4a4ef886cd8e1d3f368

• Evaluating the Risks and Opportunities of Bundled Payment Programs

– Tuesday, February 28th @ 3p EST

Registration link: https://datagen.webex.com/mw3100/mywebex/default.do?siteurl=datagen&service=6

Page 21: The Future of Bundled Payments - MHA · 2017-02-10 · The Evolution of Medicare Bundled Payment ACE BPCI CJR OCM EPM 2009 2013 Medicare Acute Care Episode Demonstration Program Medicare

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