CMS' mandatory bundled payment model: How to prepare

It should be obvious to everyone by now that value-based care is gaining acceptance and is here to stay. The latest proposed model from The Centers for Medicare and Medicaid Services (CMS), Comprehensive Care for Joint Replacement (CCJR), is CMS’ first mandatory bundled payment program and surely has organizations’ leadership wondering how they will be able to perform in such a model.

KoertnerCCJR, if implemented, will begin January 1, 2016, and it will impact hospitals in 75 Metropolitan Statistical Areas (MSA) that aren’t currently participating in BPCI (Bundled Payments for Care Improvement). The five-year program includes just two MS-DRGs (469 & 470) and phases in stop-loss for the 90-day bundles with no risk in the first year.

These programs make sense. CMS expects to save more than $150 million over the lifetime of the bundled payment model. What may not be clear is how organizations will implement the efficiencies necessary to not only survive these changes in healthcare reimbursement but to also maximize potential reconciliation payments so they earn their share of the savings.

Success will boil down to three areas of focus: preparation, partnerships, and technology.

1. Preparation

• Analyze current post-acute spending and compare to national benchmarks. Significant discrepancies may signal a breakdown in work flow, third-party partners not performing optimally, or gaps in your supply chain. Also look for duplicate services and testing that could be eliminated to reduce cost without impacting patient care.

• Standardize protocols. Best practices often lead to greater efficiency and more predictable outcomes.

• Evaluate existing staff to determine if the right people are in place to provide effective care coordination.

• Assess the technological capabilities of your organization. Are care coordinators able to easily identify high-risk patients? Is the current tracking method scalable? Is your team able to share records and communicate effectively with partner organizations? How will you monitor patients once they leave the hospital?

Next: Crucial partnerships and technology

2. Partnerships

Undoubtedly, as analysis is done on current post-acute spending, you’ll find some partners out-performing others. Organizations are going to have to align themselves with partners who deliver on high standards of care, are able to provide necessary metrics on quality, cost, and patient satisfaction, and are able to communicate effectively to prevent complications or react quickly when they arise.

Demand will be high for these partnerships, so even if you aren’t directly affected by CCJR, you should be securing these relationships now. While hospitals participating in CCJR must retain 50% of downside risk, gainsharing could be considered as a tool to ensure compliance.

3. Technology

Enough emphasis cannot be placed on the role technology has in successful CCJR participation (or any other bundled payment program for that matter). Many organizations are simply using excel spreadsheets to track patients in bundled payment programs.

While that may work for a very small population, it isn’t realistic to think they can manage innumerable patients the same way. Also, while electronic health records (EHRs) track and identify trends in patient lab values, notes, histories, and medications-for the most part they are not able to formulate or customize a plan of care or identify patients at risk of falling off that plan.

Next: Technology solutions to seek out

Technology solutions to seek out

Specialized software solutions will be necessary to effectively track patients through the continuum of care. Look for solutions that:

• Analyze risk. You have to be able to identify patients who may need additional communication or monitoring.

• Customize care plans. Patients are all different and their care plan should reflect that. Notify staff when patients fall off the plan so action can be taken immediately.

• Report. You need data that will illuminate partners performing well, identify providers who may not be following protocols, and make it possible to analyze readmission rates and length of stay for various phases of care. And, you need to know how all this information is affecting your organization financially.

• Communicate with partners no matter what EHR they are using. A technical solution must keep everyone involved in patient care informed of the plan, risk level, and expectations for each patient.

• Engage Patients. How do you know what happens to your patients once they’ve left your facility? How will patients know what to expect in terms of their care? Does your solution provide patients a means by which they can notify your organization when risks arise?

Additional technology to consider are:

• Wearable tech. Integration with your care coordination solution could provide invaluable data and go a long way to preventing readmissions.

• Telehealth. If your goal is to control costs and provide excellent care in a timely way, telehealth should be on your radar. Patients who can communicate easily with providers from the comfort of their home are far less likely to seek treatment in an emergency room, saving you thousands of dollars in your bundle.

CMS has pledged to shift 50% of Medicare payments to alternate forms by 2018. Organizations must get ready.

Karla Koertner is a certified project management professional and lead consultant at Galen Healthcare Solutions with 14 years of healthcare software experience.