Strong Signals Favor Bundled Payments to Reduce Cost of Care

October 21st, 2014 by Patricia Donovan

Besides piloting the use of bundled payments to enhance healthcare quality and efficiency, CMS's 2013 introduction of CPT codes for physician management of care transitions after discharge signals the federal payor's increased comfort with episodic-based reimbursement. Jay Sultan, associate vice president and chief product portfolio architect for TriZetto® offers his perspective on the future of bundled payments in healthcare.

Healthcare is such a cyclical industry. Anybody who says this is the new movement and it’s here to stay has a better ability to read the future than I do.

I believe that bundled payment is going to continue to increase adoption. And then I think we’ll see a pullback in rate of adoption that will be caused by two things: one will be just the fact that we’ll have picked off all the low fruit, and what’s left is harder. I’m sure there’s somebody out there who wants to do a bundle of fibromyalgia, but I don’t want any part of that. The second reason they’ll pull back is because they’ll learn some negative lessons.

One of the things about payment bundling to date, at least in the prospective payment bundling (think model four of the CMS program), is that many commercial programs are just getting started right now. One lesson to date is there just are no negative examples. There’s negative examples in retrospective payment bundling. For prospective payment bundling, we haven’t had failures yet. Those are inevitable and they’re going to come. And as they come, I think that will create a somewhat inhibiting effect.

But overall, it’s hard to imagine. What payment bundling does is change the inner purchase. We’re saying, we’re tired of buying CPT codes of services. Instead, we want to start buying longitudinal care as an episode, as a bundle. And that trend is exactly where capitation takes them, exactly where partial capitation takes us. It’s where our provider-run health plans take us. It’s just another point along the continuum of how much risk providers are taking.

I don’t think bundled payments are going to go away. CMS is signaling very, very strongly that this is part of its future, for a basic reason. It’s one of the few tools it has that can actually reduce the cost of care. For those who think that this is going to go away, I’d harken you back to the onset of DRGs. Today, DRG-based care is pretty pervasive. But it certainly doesn’t cover all of care. It doesn’t even cover all of hospital care. It doesn’t cover all of CMS hospital care.

value-based reimbursement
Jay Sultan is the associate vice president and product manager for value-based reimbursement at TriZetto®. With more than 12 years of consulting and development experience in the payer and hospital settings, Sultan is responsible for developing innovative solutions such as payment bundling and other forms of value-based reimbursement. He is also providing leadership on the adoption of clinical analytics into TriZetto solutions.

Source: Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and Methodology

Infographic: Using ICD-10 To Track Ebola Outbreak

October 20th, 2014 by Melanie Matthews

With the exception of the United States, all industrialized nations use ICD-10 to code morbidity and report disease data to the World Health Organization.

The following infographic below created by Coalition for ICD-10 illustrates the public health impact of ICD-10 in supporting the biosurveillance of the eBola outbreak.

Using ICD-10 To Track Ebola Outbreak

ICD-10-CM/PCS Implementation Action Plan ICD-10-CM/PCS Implementation Action Plan goes beyond its comprehensive coverage of ICD-10 CM/PCS to provide you with training tools, as well. This 135-page book also includes an 81-page customizeable document, as well as a customizeable spread sheet log.

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Ochsner’s Standardized Risk Stratification, Care Coordination Protocols Boost Outcomes across Continuum

October 20th, 2014 by Patricia Donovan

Ochsner Health System's scaling of a successful transitional care model across one region not only reduced duplication of calls to recently discharged patients but also quadrupled its connect rate—from about 20 percent to nearly 98 percent of discharged patients—and decreased rehospitalizations by about 15 percent.

All while remaining salary-neutral.

To achieve these results and others like them, Ochsner uniformly applied scripts, templates and protocols to processes across its care continuum, even assuming clinical oversight for some providers in external facilities to ensure standardization, explained Mark Green, assistant VP of transition management at Ochsner, during Moving the Metrics: Financial and Quality Returns from System-wide Care Coordination and Risk Stratification, an October 2014 webinar now available for replay.

To replicate these achievements, the nine-hospital system looks up and down its continuum for opportunities to collaborate in care coordination and has elevated its approach to risk stratification. This culture shift is a prerequisite for success in today's value-based climate, Green estimates.

"A really critical step to understand is managing not only your 'rising risk' but also your 'falling risk' patient population," he said, categorizing 'falling risk' as those whose conditions are under control and who can be handed off to a lower risk medical home or chronic disease management environment.

Healthcare doesn't currently do a good job of moving 'falling risk' patients down the stratification model, he said, which leaves little room for newly diagnosed 'rising risk'—an out of control CHF patient, for example.

Risk stratification is scalable, Green emphasized, from single providers without an electronic medical record to a large health system or accountable care organization. As a nine-hospital system, Ochsner's risk segmentation approach relies heavily on automation and data analytics. For example, every Ochsner hospital patient is assigned a severity of illness (SOI) level that helps to guide individuals to the appropriate level of care. For example, all level 3 patients are automatically referred to complex case management.

During the program, Green shared several of Ochsner's collaborations in risk stratification and care coordination, including an automated post-discharge telephonic follow-up for emergency department patients that replaced its siloed approach and has reduced avoidable ER use by 13 to 15 percent.

"We are very cognizant of and careful that we're not driving too much business away from our emergency room if it's appropriate. We're just letting [staff] manage a higher risk population within their emergency room and giving them time to spend more of it with the patients."

Listen to an interview with Mark Green.

Infographic: The 2014 Ebola Outbreak

October 17th, 2014 by Melanie Matthews

A new infographic by the Henry J. Kaiser Foundation provides a snapshot of the 2014 Ebola outbreak in West Africa.

The infographic includes key facts about the Ebola virus, shows how the number of Ebola cases in the current outbreak outstrips the case total from all previous Ebola outbreaks, and offers a summary of the key U.S. agencies responding to the crisis and the roles they are playing. In addition, it provides a look at the growing 2014 Ebola case count in West Africa compared to U.S. government funding commitments.

The 2014 Ebola Outbreak

Nursing Policies and Procedures for Long Term Care Nursing Policies and Procedures for Long Term Care outlines administrative policies and standards of care for basic nursing care procedures and clinical practices. The director of nursing should review and update the manual at least annually to ensure it is comprehensive and accurate. Updates should also be made when applicable due to changes in regulations or nursing standards of practice. Other appropriate additions to the manual would be manufacturer guidelines and instructions for new equipment and devices.

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Adventist Population Health Management Incentives Engage Employees, Curb Costs

October 16th, 2014 by Cheryl Miller

If employees are healthier, they're more effective, engaged in their work, and more present, says Elizabeth Miller, vice president of care management at White Memorial Medical Center (part of Adventist Health). Presenteeism is part of the company's "Engaged Health Plan," a patient engagement strategy that is targeted to save as much as $49 million overall.

To engage patients, you can offer incentives. For example, at Adventist Health we outreach to our entire organization, our own employees, and we are on track to save millions of dollars with that. We call it ‘The Engaged Health Plan’ and it’s a reduced monthly cost on their health insurance. It is a bi-weekly reduction of $50, which is significant. They’re saving $100 a month. We engaged by taking their blood pressure, their weight and their blood glucose. We created an exercise plan for them with their consent, talked to them about their physical conditioning and what they wanted to see in their physical. We also talked about the ideal health population, and how we consider a healthy employee a more effective employee.

It’s costing our organization money to put this on; even though it’s our own health plan, it does cost. Why did Adventist Health go in this direction? You can see with the cost and the savings that it will save us $49 million. It is a mission. We are a faith-based organization, but it is a mission of ours to improve the health status. And it is also going to improve us financially. If our employees are healthier, they’re more effective, more engaged in their work, more present. You’ve heard of presenteeism. These are things that we’ve looked at.

dual eligibles care
Elizabeth Miller, RN, MSN, is the vice president of care management, diabetes program at White Memorial Medical Center, Adventist Health. Ms. Miller is accountable for the daily operations of the care management team, nurse care managers, social workers and the diabetes program, ensuring optimal patient flow through the healthcare continuum of care.

Source: Population Health Framework: 27 Strategies to Drive Engagement, Access & Risk Stratification

8 Ebola Emergency Preparedness Measures from CarePoint Health

October 16th, 2014 by Patricia Donovan

Ebola drills, preparation of 'grab-and-go bags" and targeted screening of callers requesting ambulances are some of the Ebola emergency preparedness measures announced by CarePoint Health this week In response to individual cases in the United States and elsewhere.

CarePoint Health has implemented the measures system-wide at its three New Jersey hospitals and its McCabe Ambulance service.

For example, patients arriving in a CarePoint ED will immediately be screened to determine their risk of exposure to Ebola. If a case is suspected, CarePoint Health has procedures, equipment and technology in place to help limit exposure and to safely care for the patient. “We will continue to refine our plan based upon the latest information available from clinicians treating Ebola patients," said Dr. Mark Spektor, chief clinical integration officer for CarePoint Health.

Also, McCabe Ambulance's call screening technology incorporates an Ebola screening tool that prompts dispatchers to ask all callers about recent travel and critical symptoms before an ambulance even arrives at the scene. If dispatchers suspect a patient may be at risk for Ebola, EMTs can safely transfer the patient and notify the receiving hospital.

Some other immediate Ebola-related safety measures CarePoint Health has implemented include the following:

  • Ebola Drills. CarePoint Health hospitals have each begun running unannounced Ebola drills to help prepare staff members for how to deal with a suspected Ebola case. These drills will continue until the recent outbreak has been contained.

  • Creation of Ebola 'Grab and Go' bags in emergency departments. Pre-packaged bags containing all necessary personal protective equipment (PPE), instructions for donning/doffing the PPE and a checklist of how to care for patients suspected of being infected with Ebola are available in all CarePoint Health emergency departments.

  • Technology. With the new electronic medical record system, changes have been made to the screening and triage of patients making it mandatory to document travel history at intake.

  • Internal Communications. CarePoint Health is providing updates about our processes, protocols and systems to all staff members via e-mail, town hall meetings, group huddles, text alerts, and other channels. There are also targeted communications for clinical staff, emergency room personnel, security guards, housekeeping staff, communications reps and senior leadership addressing their specific protocols.

  • Regular communications with CDC and state and local health departments. CarePoint Health is in constant communication with the CDC, New Jersey and local health departments so protocols and procedures can be adjusted based upon the latest clinical data.

  • Use of personal protective equipment. CarePoint Health is conducting department specific hands-on training on the proper use of personal protective equipment. This training includes donning and doffing of equipment as well as environmental issues surrounding waste disposal.

  • Multidisciplinary task force. CarePoint Health has convened a working group drawn from its departments of clinical services, environmental services, infection control, admitting, materials management, human resources, security and others to manage its Ebola response plan.

  • Staff education. Staff members will regularly receive written educational material developed by the CDC and compiled by the Departments of Infection Control and organizational education that will address many of the questions surrounding Ebola. Full educational in-services will be provided for those staff members and our affiliated physicians who may potentially have any involvement in either the direct or indirect care of an Ebola patient.

Infographic: Is the Average Patient Ready for Telehealth?

October 15th, 2014 by Melanie Matthews

The telehealth industry is poised for significant growth, with some 350,000 users today expected to grow to 7 million by the year 2018, according to a new infographic by iTriage.

The iTriage infographic looks at who's likely to use telehealth -- by gender and by age group; the average cost for a telehealth visit and some predictions for the future of telehealth.

Are Patients Ready for Telehealth

Creating a Virtual Multi-Specialty Physician Network: A Payor-Provider Telehealth CollaborativeA collaboration between Adventist Health and Blue Shield of California is improving access to specialist care and reducing inefficiencies through virtual telehealth visits. The nine-site program, which launched in March and includes 13 specialties, will expand to an additional 16 sites by the end of this year.

During Creating a Virtual Multi-Specialty Physician Network: A Payor-Provider Telehealth Collaborative, an October 15th webinar at 1:00 p.m. Eastern, Robert Marchuk, vice president of ancillary services, Adventist Health, Christine Martin, director of operations, Adventist Health, and Lisa Williams, senior director of strategic integration and execution, healthcare quality and affordability, Blue Shield of California, will share the inside details on the collaboration and the shared mission and values of the organizations that is leading to the program's success.

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Tactics That Curb Hospital Readmissions Can Also Reduce Avoidable ED Use

October 14th, 2014 by Patricia Donovan

To reduce avoidable emergency room use, particularly by perennial high utilizers, many healthcare organizations are replicating post-discharge data mining and care coordination tactics that successfully reduce hospital readmissions—namely, heavy applications of predictive modeling supported with a blend of embedded case management, telephonic outreach and patient education.

The use of predictive modeling in particular for this purpose has jumped from one-quarter of respondents in 2011 to one-third of this year’s respondents, while ED registry and census use has jumped from 16 to 25 percent in the last three years according to results from a third comprehensive survey on reducing avoidable emergency room use by the Healthcare Intelligence Network.

Telephonic outreach to patients recently visiting the ER has almost doubled in the three-year period, with 31 percent making contact within 24 hours and 29 percent within two days.

The percentage of respondents placing either a case manager or social worker in the ED for the purpose of managing ED utilization has risen from 33 percent in 2011 to 50 percent this year.

Melanie Fox is director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care, where embedded case managers in both primary care practices and work sites use telephonic outreach to reduce avoidable hospital utilization.

“One of the goals of embedded case management is to reduce ED visits,” she says. “This is one of the harder things to be able to manage but it is a goal. We don’t know our outcomes yet, although I am starting to measure that.

“We do a lot of education with patients when we follow up,” Ms. Fox continues. “We look and see how many times they’ve been to the ER, and if they’re abusing the ER. Maybe they don’t really have a way to get to the hospital or to the doctor’s office; they end up in a hospital because they don’t have a ride to the doctor. We try to get them to be more proactive with their care. If they let us know ahead of time about a health issue, we can help them stay out of the ER.”

Ochsner Health System is also applying its automated and risk-based post-hospital-discharge follow-up approach to its ED population, connecting them to community resources, a nurse advice line, or the opportunity to schedule a follow-up appointment, depending on need. The process has reduced avoidable ER utilization by between 13 and 15 percent, depending upon payor and location, according to Mark Green, system AVP for transition management at Ochsner Health System. Rather than driving business away from Ochsner ERs, “We’re just letting [ER staff] manage a higher risk population within their emergency room and giving them time to spend more of it with the patients,” explains Green.

Excerpted from: 2014 Healthcare Benchmarks: Reducing Avoidable ER Visits

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Avoidable-ER-Visits-_p_4942.html

2014 Healthcare Benchmarks: Reducing Avoidable ER Visits delivers actionable metrics from 125 healthcare organizations on their efforts to foster appropriate use of hospital emergency departments.

Infographic: How Will the November Election Impact Medicaid Expansion?

October 13th, 2014 by Melanie Matthews

Some of the November governors’ races could impact the number of states with Medicaid expansion programs, according to a new infographic by Families USA.

There are currently 23 states that have not chosen not to expand Medicaid. Of those, 15 have gubernatorial races in November, setting the stage for potential Medicaid expansion in 2015. The infographic looks at the governors’ races likely to have the greatest impact on whether the state expands Medicaid.

Governors' Races and Medicaid Expansion

Medicaid Expansion: Mid-Year 2014 Results Medicaid Expansion: Mid-Year 2014 Results includes enrollment statistics by state, company and county, plus details of financial results and market strategies for major Medicaid players. Packed with the latest available data, the report provides a thorough picture of how the Medicaid market is shaping up right now. Medicaid expansion continues to provide tremendous new opportunities for health plans, states and the uninsured.

Medicaid Expansion: Mid-Year 2014 Results will provide your management team with a quick, thorough and accurate reading of the results to date, and a window into the opportunities ahead.

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4 Factors Driving Resurgence in the Physician-Hospital Organization Model Today

October 10th, 2014 by Cheryl Miller

As healthcare organizations seek the infrastructure to respond to emerging payment models like accountable care organizations (ACOs), bundled payments, narrow networks and direct contracts, the physician-hospital organization (PHO) model is experiencing a resurgence nationwide.

But will it work this time? Four factors make the PHO attractive, says Travis Ansel, senior manager with the Healthcare Strategy Group, during Preparing for Value-Based Reimbursement Models: PHO Development for ACOs, Bundled Payments and Direct Contracting, a 45-minute webinar from the Healthcare Intelligence Network (HIN) now available for replay.

The first most immediate driver is independent physician alignment, says Mr. Ansel. While most markets are mature in terms of employment, there are still a number of markets where there are a significant number of independent physicians in key specialties. In these areas, the PHO model is more of an initial catchall type of alignment model, one that creates a loose tie between the hospital and the physicians in the market, and provides value to the physicians in terms of being protected as part of a larger group without having to become employed. One benefit for the hospitals is that they can align independent physicians en masse and create common incentives, instead of having to negotiate alignment models or arrangements with all independent physicians in their market.

The second driver is the increasing mutual accountability for quality and cost across providers. In the wake of transitioning payment models under payment and insurance reform, insurers and payors are trying to drive mutual accountability for patient costs to physicians and hospitals. The PHO is an appropriate response for those providers to work together to manage the cost of a population and of an episode of care in order to make sure everybody’s successful.

The third factor driving resurgence in PHO activity is the consolidation and distribution of resources that will allow providers to be successful in managing quality and cost. As healthcare reform and payment reform mature, information technology (IT) competencies, clinical competencies, care coordination practices, and exploring the patient-centered medical home (PCMH) concept are often unrealistic at the individual practice level. The PHO gives physicians and hospitals the platform to work on those care competencies together, build them in one place and then distribute them to PHO members — a “win-win for everybody,” Mr. Ansel says.

The final driver is the need for an effective framework for clinical integration. While there are already a number of clinically integrated organizations around the country, “For the bottom 90 percent of healthcare organizations in the country, clinical integration is still that thing that’s on our to-do list, but it always gets bumped to the back of the to-do list; because, we have more immediate needs, or more immediate strategic priorities,” Mr. Ansel says. Clinically integrated models are needed as a strategy to respond to payment reform, to allow joint contracts between physicians and hospitals, and to enable sharing of payments effectively, whether those are shared savings payments, bundled payments, etc. Adds Mr. Ansel:

"The PHO model provides a great initial step to building that clinically integrated network platform, and gives providers and the hospital a great model for working together to start building the competencies towards a clinically integrated network."

Click here for an interview with Mr. Ansel.