Bundled Payment for Care Improvement Initiative (BPCI)

7/8/2017

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Bundled Payment for Care Improvement (BPCI)

Overview

Shawn Matheson

MBA, LNHA, FACHCA

Market Manager

Idaho Health Care Association

Annual Convention

Boise, ID

July 13, 2017

Retrospective Bundles

Retrospective

Reconciliation

SurgeonHospitalSNFHome Health

FFS Billing

as Usual

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PAC OPPORTUNITY & RISK FROM HOSPITAL EYES

Inpatient Rehab Facility, Long-term Acute Care, Skilled Nursing Facility

Home Health

Surgeon,Hospital

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PAC OPPORTUNITY & RISK FROM HOSPITAL EYES

HospitalDischarge

90-DayBundle

Risk

Inpatient Rehab Facility, Long-term Acute Care, Skilled Nursing Facility

Home Health

Surgeon,Hospital

Hospitals are Increasingly Responsible for the

Financial & Quality Outcomes for a Patient’s Entire

Episode of Care

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• Creates accountability for positiveoutcomes and efficiency

• Engages clinicians and drives a shift to coordinated, multidisciplinary care over the full Episode

• Promotes competition in an increasingly uncompetitive market

• Patients can choose the Provider that best fits their specific needs

• Providers with the greatest efficiency & best outcomes will grow, improving overall average outcomes and reducing average costs

• Providers with poor performance will need to either improve, or exit focus on areas where they can deliver clear value

Why Bundled Payments Work

OPPORTUNITY OVERVIEW | REMEDY OVERVIEW | 04.28.16

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Remedy has created a comprehensive episode of care company with the largest footprint and broadest range of bundled payment capabilities: enabling Payers and Providers to succeed with bundled payments

Remedy

Partners

Hospitalists

ACH

SNFs

PGPs

Other

Convener Share By Competitor Remedy’s Bundled Payment Spend By Partner ($6.7B)

Remedy Partners Overview

66%

$6.7B$44 M

1%

$4,505M

67%

$1,515M

23%

$359M

5%

$263M

4%


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7

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2

65k

-

1

2

3

4

5

6

7

8

2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2

Remedy Spend Under Management

2015 Q1 – 2016 Q2

Remedy Episodes Under Management

2015 Q1 – 2016 Q2

Remedy Partners Overview

Episodes$ Billions

Spend & Episodes


$6.7b

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• Remedy’s role is to manage the bundled payment program for its Payer Partners including the development, organization, operationalization and ongoing management of the program

• Remedy supports its Partners with the technology, analytics, expertise, and process implementation to operationalize the program, along with technology and care protocols to efficiently manage the complex program

Remedy’s Role in Program Success

Program Design

& Administration

• Care coordination programs

• Contracts and protocols

• Compliance, Quality and Reconciliations

Software Tools

• Episode Connect

• Patient attribution, patient tracking

• Assessment, patient stratification and decision support

• Portals

Analytics

• Risk mitigation and actuarial support

• Predictive analytics

• Comprehensive reporting

Network Management,

Call Center

• SNF and HHA Performance Networks

• Post Acute Physician Network

• Care Innovation Center

BPO for Bundled Payments


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Full Bundle Administration

• Acute myocardial infarction

• Amputation

• Atherosclerosis

• Automatic implantable

cardiac defibrillator

• Back and neck except spinal fusion

• Cardiac arrhythmia

• Cardiac defibrillator

• Cardiac valve

• Cellulitis

• Cervical spinal fusion

• Chest pain

• Chronic obstructive

pulmonary disease

• Combined anterior posterior

spinal fusion

• Complex non-Cervical spinal fusion

• Congestive heart failure

• Coronary artery bypass graft surgery

• Diabetes

• Esophagitis, gastroenteritis

other digestive disorders

• Double joint replacement/

lower extremity

• Fractures femur and hip/pelvis

• Gastrointestinal hemorrhage

• Gastrointestinal obstruction

• Hip and femur procedures

except major joint

• Lower extremity and humerus

except hip, foot, femur

• Major bowel

• Major cardiovascular procedure

• Major joint replacement

of the lower extremity

• Major joint replacement

of upper extremity

• Medical non-infectious orthopedic

• Medical peripheral vascular disorders

• Nutritional and metabolic disorders

• Other knee procedures

• Other respiratory

• Other vascular surgery

• Pacemaker

• Pacemaker Device replacement

or revision

• Percutaneous coronary intervention

• Red blood cell disorders

• Removal of orthopedic devices

• Renal failure

• Revision of the hip or knee

• Sepsis

• Simple pneumonia and

respiratory infections

• Spinal fusion (non-Cervical)

• Stroke

• Syncope and collapse

• Transient ischemia

• Urinary tract infection

48 BPCI Bundles Representing 181 DRGs covering up to 50% of MLR


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Remedy’s existing Partnerships are a platform for serving local Payers and self-funded employers

Remedy Assets for Success

Remedy Network


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Episode Connect: Provider Platform

The Operating System for Bundled Payments

User Portals

Separate views for case managers, program administrators, patients and physicians

Data Aggregation

Integration with HL7 feeds from most major EMR systems

Patient Attribution

Predictive analytics for early DRG assignment and workflow tools to set up patients accreting into bundled payments

Onboarding & Assessment

Patient risk stratification and post-acute needs assessment

Messaging & Alerts

Dynamic care team creationand downstream/multi-channel messaging and alerts

Open API

Full scale enterprise software capabilities enable deep integration with EMRs

Content & Engagement

Disease and condition-specific digital check-ups, plans for care coordination plans, dietary and supplement protocols, episode length of stay guidelines

Workflow Tools

Patient tracking and coordination software for call centers, case managers, administrators and physicians

Reporting & Analytics

Advanced patient and population level analytics, including process and performance reports to manage and track progress

Decision Support

Validated software tools to guide selection of best site for post-acute care and to calibrate post-acute


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Remedy expects to deliver ~$100 million of savings to Medicare in 2016

Current Operating Results

Gross Savings Improvement Average Readmission Rate

Discharge to SNF Rate Average SNF Days per Episode

35%29%

Q1 2014 Q1 2015

~6% reduction34.7

29.2

Q1 2014 Q1 2015

~15% reduction

30%25%

Q1 2014 Q1 2015

~17% reduction

~320 bps improvement ~570 bps improvement

0%

4% 4%

9%

Q1 2014 Q1 2015 Q1 2014 Q1 2015

Model 2 Model 3


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Model 3 Opportunities for SNFs

1. Only 6% of SNFs in the country have put their revenue at risk

2. Model 3 SNFs have a strong incentive to achieve high-quality, low-

cost outcomes

3. Remedy’s partnership with 435 Model 3SNFs represents over 60%

of the entire BPCI Model 3 Program.

4. Helps with Model 2 Providers to see Model 3 Partner Commitment

5. Can retain savings compared to Adjusted Historical Rates

6. Advanced BPCI Forthcoming, narrow window to enroll

[email protected] | 801-856-8155

Shawn Matheson

Bundled Payment for Care Improvement Initiative (BPCI)

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SAHS Director: Becky Swenson, MSN, MHA, RN, NEA-BC

7/8/2017

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BPCI Initiative

Key Terms:

Bundles: There are approximately 181 DRGs collapsed into 48 Clinical Bundles

Episode of Care (Episode): An episode begins upon hospitalization and includes

most services covered by Medicare Part A & B provided to the patient over a

period of 90 days – including the inpatient stay and the period after discharge,

termed the post-acute period

Baseline Price: Based on the Episode Initiator's (provider’s) historic average costs

between July 2009 and June 2012

Target Price: Historical spending/price set by CMS against which current spending

is compared to determine savings or penalties in the BPCI program

Funds Flow (Revenue Cycle): CMS continues to pay FFS claims directly to doctors

and hospitals; episodes are reconciled retrospectively against a Target Price

Episode CostsFor a typical Model 2 90-day bundle, Medicare spends more on a patient’s post-

acute care than their initial hospitalization.

34.9%

20.6%

14.3%

Anchor

AdmitSNF Readmissions Home

Health

Long Term

Care

Inpatient

RehabPart B DME Outpatient

4.6%

1.9%3.7%

15.0%

0.9%

4.1%

Patient Eligibility

Patients are automatically enrolled in the BPCI program if they meet all of the necessary criteria.

Medicare is the primary payer

Enrolled in Part A & B for the entire episode of care

Condition falls into selected bundles

Pt is only enrolled in one episode at a time

Medicare is not the primary payer for the entire episode

Medicare coverage is changed or dropped

Pt has ESRD

Pt is covered under United Mine Workers

Necessary Criteria Excluding Criteria

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Key Levers of Success

Strong Patient Navigators

Appropriate Next Site of Care Decisions

Optimal Lengths of Stay at Next Site of Care

Strong Preferred Provider Networks

Early Intervention

Minimal Readmissions

What We Ask of Our Partners

Manage Length of Stay (Meet/Exceed ELOS)

Weekly Care Conferences Involving Pt Navigators

Implement Tools to Prevent Readmissions

Questions?

7/8/2017

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Medicare Shared Savings Program (MSSP)

Accountable Care Organization (ACO) – Track

3

Elizabeth Barber, MSN, RN, CCM

Manager, Alliance Clinical Team (ACT)

2017

CMS Shared Savings Program -

MSSP ACO Track 3

• Established by section 3022 of the Affordable

Care Act

• ACOs partner with CMS in Advance Payment

Models Contracts (APMs)

• ACOs are groups of doctors and other healthcare

providers who voluntarily work with CMS to

provide high quality, cost effective care to

Medicare Fee for Service Beneficiaries

• Saint Alphonsus was an independent Track 1

(Pioneer Model) for 2 years (2015-16)

• Now a Track 3 Chapter participant (1 of 5) under

Trinity Health Integrated Care (THIC, LLC)

• Track 3 offers shared savings AND is a risk

model – if we don’t perform, we write a check

back to CMS

• Track 3 has several different benefits/structures

from Track 1 – of note, the 3 day SNF waiver

MSSP ACO T3 Patient Eligibility

• Traditional FFS Medicare is the

primary payer (A&B)

• Patients may be dual eligible

(Medicare/Medicaid)

• Patient cannot “opt out” of ACO

• Must be assigned by CMS to the

ACO and on the current year master

beneficiary list

• Patients retrospectively assigned

from CMS using their methodology –

largely claims based – can attribute

to PCP or Specialist

• Most participating attributed

providers are SAMG – one

independent provider group

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Proving “High Quality Care”

Some have higher implications for care

management than others:

• Cost savings (must meet a minimum threshold

to account for natural variance)

- Reduce unnecessary utilization (ED/1000,

IP/1000, readmit/1000)

- Right level of care/right time (reduce SNF

LOS, utilize 3 day SNF waiver)

- Care Coordination/Care

Management/Transitions

• Quality: meet report and/or performance

thresholds for 34 quality measures

• Mandatory Reporting Requirements

• EHR utilization (at least 50%)

• Patient satisfaction (CAHPS) Survey for ACOs

3 Day SNF Waiver Patient Eligibility

• Assigned to the ACO in year

admitted to eligible SNF

• Does not currently reside in SNF or

other LTC setting

• Medically stable – does not require

(further) inpatient

evaluation/treatment

• Has a confirmed diagnoses

• Has identified skilled nursing or

rehab need that cannot be met

outpatient

• Evaluated and approved for

admission by an ACO physician

3 Day SNF Waiver SNF Eligibility

• Must be enrolled in Medicare

• Existing written SNF Affiliation

Agreement with ACO

• SNF must have and maintain

an overall 3 star Quality Rating

(this is verified monthly by the

ACO and affiliate will be

removed immediately if they fall

below)

• Other quality/reporting

components as determined by

ACO, such as…

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Preferred Post-Acute Providers (PAP)

• Quality data reported to ACO at

regular intervals (SNF LOS,

readmit rates, etc.)

• Collaborative Care Coordination –

RN care managers attend

meetings, works with PAP to follow

and update Care Plan

• Engagement in collaborative post-

acute initiatives (clinical care

guidelines, patient education)

• 24/7 liaisons available for SNF

waiver

• Still a work in progress…

Questions?

Bundled Payment for Care Improvement Initiative (BPCI)

Documents

Transcript of Bundled Payment for Care Improvement Initiative (BPCI)