Implementing a Bundled Payment Payment Program Bundled Payment Summit June 16th, 2014 Proprietary &

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Implementing a Bundled Payment Program

    Bundled Payment Summit

    June 16th, 2014

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Agenda •  Implementation Overview: Step-by-Step •  Data Preparation •  Data Driven Metrics and Decision Making •  “Big Picture” Analytical Tools •  Budget Creation •  Risk Adjustment •  Assessing Quality •  Scaling BP •  The HCI3 Learning Center

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Implementation Overview: Step 1 Data Analysis •  The beginning and end of all successful

    payment reform program is robust data analysis

    •  Otherwise, all parties are steering in the dark

    •  Seeing is believing; and believing is committing

    •  Payment reform, in the final analysis, is really about transforming information

    3

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    The Contracting Dyads

    Governments (Medicare / Medicaid / State Employee Programs)

    Health Plans, HMOs, PPOs, Co-ops, TPAs

    Employers Direct Contracting*

    ACOs and Large Health Systems

    Free Standing Surgical Centers

    IPAs and Hospital / Physician Groups

    Specialist Line of Service Groups (Ortho, OB/GYN, etc)

    Primary Care / Medical Homes

    Buyers Sellers

    *this one alone is sending shock waves through the “planosphere”

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Step 2: Leadership Commitment

    C-Suite

    Data Analysts

    IT

    Business Management

    Plan / Payer(s)

    Physician Leadership

    Quality Management

    IT

    Network Management

    Providers

    Convening Organization

    Implementation Methods

    Steering Committee

    Leadership Plan PM Prov. PM

    Clinical Staff

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Step 3: Payer / Provider Engagement

    Kick-off Meeting •  A well crafted agenda that both parties have agreed to •  Sets the tone and tenor of the entire project going

    forward •  Assign roles and responsibilities: Good PMs •  Star Agenda Item: data analytics (which is really the

    beginning of contract negotiations) •  Retrospective vs. Prospective payment •  Action items and deliverables •  Dashboards with (realistic) milestones •  Follow-through procedures to Launch

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Step 4: Scoping the Project

    Scoping comes in 4 “Boxes” The Bundle Set

    Responsible Individuals

    Quality Scorecard

    The Engine

    Which and how many episodes are in the dyad?

    Who is responsible for what within the dyad?

    How will we measure (and operationalize) effectiveness?

    When will we move to scale?

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Managing Dyads – Layering Scope

    Orthopedic Bundles

    Coronary Bundles

    Condition Bundles (PCMH)

    Master Scope

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Step 5 and Beyond: Launch

    Observation Year: ECR Analytics over FFS

    PAC Reduction: Upside only Contract

    PAC Reduction: Contract with Downside

    Full Prospective Payment

    •  “Brass Tacks” of operationalizing BP program

    •  And negotiating contracts •  Benefits redesign (?) •  Launch date(s) •  Pathway and program expansion

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    For contact information: www.HCI3.org www.bridgestoexcellence.org www.prometheuspayment.org

    Questions?

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Data Preparation: Clearing the Pathway for Analytics

    Bundled Payment Summit June 16 2014

    Jenna Slusarz, Program and Operational Support, HCI3

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Basic Files Required

    •  Member File –  one record per member

    •  Enrollment File –  Multiple records per member

    •  Provider File –  One record per provider_id present in the stay and professional

    files •  Inpatient Stay File

    –  All claims for a single admission rolled up into one record with all codes and final allowed amount

    •  Professional File –  Line level file –  Contains professional, outpatient facility and ancillary claims

    •  Pharmacy File

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Know Your Data

    •  What do you expect to see? –  What range of costs would you consider

    normal for each claim type within your data? •  What are your data limitations?

    –  Missing fields? –  Quirks?

    §  Missing costs for a certain payer §  Putting all unknowns under 1 provider id

    or member id –  Unreliably reported fields

    13

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Are Data Supplements Available?

    •  If you have missing or unreliably filled-in fields, is there a secondary data source you can use?

    – Ex. NPI database to fill in missing specialties

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Know Your Data Structure

    •  If you don’t understand how your data is structured and stored you wont be able to accurately structure it for analysis and can’t rely on the results to be accurate

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Data Needed for Episode Analytics •  Claim Information

    –  Allowed amounts (claim and line level) –  Diagnosis and procedure codes

    §  ICD- 9 DX §  ICD-9 PX §  CPT/HCPCS §  Revenue codes

    –  Dates of service –  Facility type

    •  Consistent member ids and provider ids •  Member information

    –  Enrollment –  Age/YOB

    •  Provider information (specialty, group, etc.) 16

  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Data Structure: Why Use PX And DX Versus DRG? •  DRG matches DX, doesn’t take PX into account

    MS_DRG_ CODE

    DRG description DXCCS DXCCS_DESC

    Principal_ proc_code PXCCS PXCCS_DESC

    313 CHEST PAIN '102' 'Chest pain' 4523 '76' 'Colonoscopy ' 313 CHEST PAIN '102' 'Chest pain' 4525 '76' 'Colonoscopy ' 313 CHEST PAIN '102' 'Chest pain' 4292 '69' 'Esoph dilat ' 313 CHEST PAIN '102' 'Chest pain' 3995 '58' 'Hemodialysis' 313 CHEST PAIN '102' 'Chest pain' 0392 '5' 'Inject spine' 313 CHEST PAIN '102' 'Chest pain' 9390 '216' 'Mech ventil ' 313 CHEST PAIN '102' 'Chest pain' 8605 '174' 'nOR Rx skin ' 313 CHEST PAIN '102' 'Chest pain' 8843 '191' 'Ot arterio ' 313 CHEST PAIN '102' 'Chest pain' 8838 '180' 'Ot CT scan ' 313 CHEST PAIN '102' 'Chest pain' 9205 '209' 'Ot fct scan ' 313 CHEST PAIN '102' 'Chest pain' 0017 '231' 'Ot Rx procs ' 313 CHEST PAIN '102' 'Chest pain' 3893 '54' 'Ot vasc cath' 313 CHEST PAIN '102' 'Chest pain' 3782 '48' 'Pacemaker ' 313 CHEST PAIN '102' 'Chest pain' 8941 '201' 'Stress tests' 313 CHEST PAIN '102' 'Chest pain' 8942 '201' 'Stress tests' 313 CHEST PAIN '102' 'Chest pain' 3142 '35' 'Tracheoscopy' 313 CHEST PAIN '102' 'Chest pain' 4513 '70' 'UGI endosc ' 313 CHEST PAIN '102' 'Chest pain' 4516 '70' 'UGI endosc ' 313 CHEST PAIN '102' 'Chest pain' 5794 '108' 'Urine cath ' 313 CHEST PAIN '102' 'Chest pain' 9955 '228' 'Vaccinations'

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  • Proprietary & Confidential. Health Care Incentives Improvement Institute, Inc.

    Data Structure: Why Use PX And DX Versus DRG?

    ms_drg _code DRG Description

    Principal_proc _code

    PXCC S

    PXCCS_D ESC

    principal_ diag_code DXCCS DXCCS_DESC

    235 CORONARY BYPASS W/O CARDIAC CATH W MCC 3611 '44' 'CABG ' 41041 '100' 'Acute MI'

    235 CORONARY BYPASS W/O CARDIAC CATH W MCC 3611 '44' 'CABG ' 41071 '100' 'Acute MI'

    236 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 3611 '44' 'CABG ' 41011 '100' 'Acute MI'

    236 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 3611 '44' 'CABG ' 41041 '100' 'Acute MI'

    236 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 3611 '44' 'CABG ' 41071 '100' 'Acute MI'

    236 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 3611 '44' 'CABG ' 41091 '100' 'Acute MI'

    •  DRG matches PX, doesn’t take DX into account

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