Why move to bundled payments will challenge providers’ IT skills

As payers increasingly move to alternative models for reimbursement, healthcare organizations will require new IT capabilities in order to survive.

While Washington’s current legislative healthcare debate is primarily focused on access to medical care, many in the industry remain concerned about other reform measures that address quality and cost of care.

Shifts to payment methodologies such as bundled payments will have big implications for providers, not the least of which is how they'll need to adapt information systems to achieve desired results under new payment incentives.

The future around bundled payments appears somewhat clouded, at least for the near term. This past week, the Centers for Medicare and Medicaid Services delayed the start of mandatory bundled payment models—for cardiac and orthopedic care, and for the Cardiac Rehabilitation Incentive Payment Program—to January 1, 2018, from May 20, 2017. The CMS’ final ruling will affect episode payment models that target 90-day care episodes.

However, experimentation is already underway. Today, approximately 1,300 hospitals, physician groups and post-acute providers nationwide participate in the CMS’ voluntary Bundled Payment for Care Improvement (BPCI) model. These providers are redesigning and improving care delivery for one or more of 48 conditions. Commercial payers also are starting to align with CMS’ bundle definitions as healthcare continues to undergo a transformation in both payment models and care delivery.

Despite the delay of the mandatory program, the general consensus is that the overall approach for bundled payments is here to stay in some form for both public and private payers. Bundled payments represent the ultimate form of accountability, by linking the payments made by a payer for multiple services a patient receives from providers during an episode of care. These arrangements with providers are intended to ultimately place focus both on financial and performance—which includes quality, patient satisfaction and more—thus representing a dramatic shift from fee-for-service arrangements.

Bundled payments also represent a sea change for providers’ use of information technology. It will place growing demands for interoperability that enables the exchange of patient information for all providers who treat a patient receiving care under a bundled arrangement. It will also burden provider billing systems, which now are currently designed around tracking patient services and billing for them in a fee-for-service model. Finally, systems will need to ensure high-quality care, eliminating medical errors and promoting best practices that achieve the best possible results.

To help understand this important evolution in care, Chasm Partners recently brought together three recognized thought leaders for a roundtable discussion to dive into the current state and future of bundled payments. Discussion participants included:
  • Patrick Conway, deputy administrator for innovation and quality and director of the Center for Medicare and Medicaid Innovation and the Centers for Medicare and Medicaid Services.
  • Niyum Gandhi, executive vice president and chief population health officer of Mount Sinai Health System.
  • Jean Drouin, MD, CEO and co-founder of Clarify Health Solutions.

Here are some of the key takeaways from the bundled payment roundtable.

Bundled payments are an innovative alternative payment model that needs to be supported by other forms of innovation to be successful. “We have been impressed by the level of engagement of providers in bundled payments...the amount of innovation in the marketplace focused on better patient care is exciting,” Conway said. “For example, providers are using evidence-based protocols and team-based care to guide decision-making. Providers are using data and risk assessment to determine the best setting for post-acute care. We are seeing providers use telehealth and home care in innovative ways to support patients in their homes.”

Providers need to be rewarded for supporting value-based care—and you can’t reward what you can’t measure well. “Bundles are a tremendous improvement over fee-for-service by providing a standardized yardstick to track and assess value,” Drouin said. “But it’s important to remember that the purpose of bundles is not to lock down care to a few set pathways, but rather to provide a language to facilitate the identification of positive and negative practice patterns—and to reward clinicians and providers based on value creation.”

He added: “The better and richer the data available, the more sophisticated the predictive analytics can be to validate good variation versus unhelpful practice.” The San Francisco-based healthcare technology company that Drouin leads, Clarify Health Solutions, is focused on providing predictive analytics and real-time workflow solutions for episodes of care, including bundled payments.

Even within the context of high-value innovation, providers must fully understand and embrace the operational improvements required to drive outcomes under bundled payments. “For bundles with significant post-acute spend, integrating pre-operative navigation with hospital case management and discharge planning is critical,” Gandhi said.

In addition, he explained that for bundles that have high spend on implantables or devices, there will likely be a greater focus on managing sourcing and variation. “If a bundle includes the ability to shift site of service—such as an orthopedic bundle that triggers based on the surgery irrespective of whether it occurs inpatient or outpatient—then demand-matching and all of the associated analytics and navigation become most critical,” Gandhi said.

Drouin explained why innovation and operational improvements are inextricably linked, especially in a healthcare setting. “In contrast to industries such as logistics or retail, providers have only begun to unlock the benefits of episodic care model and workflow redesign, which demands a different approach and mindset. Bundles necessitate quarterbacking far beyond the confines of the hospital EMR, across multiple care sites, including the home.”

Doing that successfully requires the implementation of a technology platform to enable automated systems of longitudinal engagement, “where the patient is monitored and piloted from the beginning to the end of the bundle journey,” Drouin added.

Participants agreed that providers will need to fully optimize information systems to manage bundled payment requirements and thrive in this new world. The transition will be very quick and profound, says Gandhi of Mount Sinai.

“I think we’ll eventually see a resurgence of mandatory bundles in the public space. Whether this happens five years from now or 25, it seems that bundles may eventually become ‘the new DRG,’ such that many inpatient admissions are reimbursed at a fixed rate for 30 or 90 days, rather than just for the acute admission,” he says. “From the health system perspective, for this to work, there is a lot that will need to be worked out to ensure adequate risk adjustment, appropriate regulatory changes to allow hospitals to manage post-acute care more effectively, and the right glide path to uniform market rates. A blunt implementation of this sort of change could backfire, but a deliberately nuanced approach could yield significant quality and efficiency improvement in the long term.”

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