Jhc may18

May 2018 • Vol.9 No.3

Cracking the Code Bundled-payment programs are alive and well. The proof is a brand new program – Bundled Payments for Care Improvement Advanced – which was introduced in January by the Centers for Medicare & Medicaid Services.

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CONTENTS »» MAY 2018

4 High-tech Home Care 6 Surgical Wound Monitoring from Home 8 Cracking the Code

Bundled-payment programs are alive and well. The proof is a brand new program – Bundled Payments for Care Improvement Advanced – which was introduced in January by the Centers for Medicare & Medicaid Services.

20 Contact Precautions: When to Stop.

22 In the Dark

State Medicaid agencies fail to report critical information about assisted living services

The Journal of Healthcare Contracting is published bi-monthly

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The Journal of Healthcare Contracting (ISSN 1548-4165) is published bi-monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153.

Copyright 2018 by Share Moving Media All rights reserved.

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The Journal of Healthcare Contracting | May 2018

3

HOME CARE

High-tech Home Care

providers’ field of view so they don’t have to switch focus between what they are doing with their hands and the content they need to see to do their job, according to Trinity Health. The telehealth provider will be swyMed.

Catholic healthcare delivery system Trinity Health said

With the combination of Glass and

it will test the efficacy of Internet and video technologies com-

swyMed, secondary providers should be

bined with home visits by secondary caregivers, to determine

able to do assessments of recently re-

how the technologies may increase access to primary care phy-

leased and chronic care patients – in real

sicians and advance people-centered care. Based in Livonia,

time and in the patient's home – with-

Michigan, Trinity Health includes 93 hospitals as well as 120

out the burden of having to hold a video

continuing care programs, which include PACE, senior living fa-

camera or a tablet, says Trinity Health.

cilities, and home care and hospice services.

4

Clinical simulation of the technologies

The Internet technology from Glass Enterprise Edition is a very

was scheduled to begin in late summer

small computer with a transparent display that clips onto glass-

at the Loyola University Health System in

es or industry frames. It brings information into the secondary

Maywood, Illinois.

May 2018 | The Journal of Healthcare Contracting

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WOUND CARE

leads to the common and frustrating scenario where patients present to a routine, scheduled clinic appointment with an advanced wound complication that requires readmission, with or without reoperation.”

Forty vascular surgery patients were enrolled in the study. Each was provided an iPhone 5S and an accompanying visual reference guide to assist in using the

6

Surgical site infections are the most expensive hospital-acquired infection, costing an average of nearly $30,000 per woundrelated readmission and an estimated $3 billion to $10 billion annually.

Surgical Wound Monitoring from Home

phone and app. During the study, seven

A smartphone app called WoundCare is successfully

wound-monitoring protocol requires a

enabling patients to remotely send images of their surgical

dedicated transitional care program and

wounds for monitoring by nurses. The app was developed by

not simply adding a task to the current

researchers from the Wisconsin Institute of Surgical Outcomes

staff workload. This protocol also has a

Research (WiSOR), Department of Surgery, University of Wiscon-

cost-savings component, in addition

sin, Madison, with the goal of earlier detection of surgical site

to the patient safety and satisfaction

infections and prevention of hospital readmissions. The study

aspects, study authors noted. Surgical

results appeared on the website of the Journal of the American

site infections are the most expensive

College of Surgeons.

hospital-acquired infection, costing an

wound complications were detected and one false negative was found.

Study authors note that the success and sustainability of a post-discharge

“Patients cannot identify [infections] and frequently ig-

average of nearly $30,000 per wound-

nore or fail to recognize the early signs of cellulitis or other

related readmission and an estimated

wound complications,” study authors wrote. “This drawback

$3 billion to $10 billion annually.

May 2018 | The Journal of Healthcare Contracting

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Cracking the Code

Bundled-payment programs are alive and well. The proof is a brand new program – Bundled Payments for Care Improvement Advanced – which was introduced in January by the Centers for Medicare & Medicaid Services.

JHC readers may recall that neither former HHS Secretary Tom Price or Centers for Medicare & Medicaid Services Administrator Seema Verma were fans of mandatory bundled programs. In fact, they cancelled one program for cardiac care and scaled back another for orthopaedic joint replacement.

But they didn’t count out voluntary programs. Neither has Price’s successor, Alex Azar.

In bundled payment programs, a group of acute- and non-acute providers agree to share the financial rewards of providing cost-effective, high-quality care to patients across a 90-day period (called a “Clinical Episode”), or bear the penalty for providing care that is too costly or of poor quality. Each provider continues to receive its fee-for-service reimbursement from Medicare. But if, collectively, they care for a patient across an entire Clinical Episode for less than the Medicare “target” cost (while maintaining certain quality standards), they share the savings.

8

May 2018 | The Journal of Healthcare Contracting

Rx Only ©2016 B. Braun Medical Inc. Bethlehem, PA. All rights reserved. 16-5430_JHC_5/16_RTS3

REIMBURSEMENT

The whole point is this: Providers across the care

“The administration has always supported volun-

continuum are encouraged to work together to reduce

tary models where providers can opt in, embrace

the cost and improve the quality of a patient’s care.

a more flexible model structure, and qualify for

Re-engineer care along the continuum

greater incentives. The industry has been hungry for more programs like BPCI, and we believe BPCI Advanced signifies the future of value-based care.”

Some of the fine print in BPCI Advanced differs

Says Mark Hiller, vice president of bundled pay-

from that in the original BPCI program, which was

ment services at Premier, BPCI Advanced “most defi-

launched in 2013. But its intent is the same:

nitely indicates a strong movement toward value-

• Support providers who are interested in continuously re-engineering care.

• Eliminate unnecessary or low-value care, increase care coordination and foster quality improvement.

based payment, with bundles being one of the most impactful models amongst several others that are now qualified for Advanced Alternative Payment models under MACRA.

• Test a payment model that creates extended

“Bundled payments are a tried and true mech-

financial accountability for improved patient

anism that promotes integrated processes, op-

outcomes and reduced spending.

erational efficiencies, physician engagement/ alignment, and cross-continuum

“ We have witnessed incredible success for those organizations who ‘crack the code’ for bundled payments.”

– Mark Hiller

relationships for both patients and healthcare organizations.”

Post-acute providers will be pivotal in bundled payment programs, says Hiller, pointing out that skilled nursing facilities made up almost half of the BPCI participants.

BPCI Advanced will launch on

• Stimulate rapid development among providers

October 1, 2018, and the Model Period Performance

of new, evidence-based knowledge, that is, the

will run through December 31, 2023. CMS said it

Learning System.

would provide a second application opportunity in

• Increase the likelihood of better health at lower cost through patient education and ongoing communication throughout the clinical episode.

January 2020.

Redesign care delivery A BPCI Advanced “Clinical Episode” begins either at

10

“This effectively is a stake in the ground for the

the start of an inpatient admission to an acute-care

continued growth of value-based programs that

hospital (a so-called Anchor Stay) or at the start of

reduce costs and deliver better care,” says Clay

an outpatient procedure (an Anchor Procedure). In-

Richards, CEO and president, naviHealth, a Cardinal

patient admissions that qualify as an Anchor Stay

Health company that focuses on care transitions.

will be identified by MS-DRGs, while outpatient May 2018 | The Journal of Healthcare Contracting

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PATIENT CARE

ENVIRONMENT OF CARE

INTERVENTIONAL CARE

REIMBURSEMENT

procedures that qualify as an Anchor Procedure

Lessons learned What are the top three lessons learned by providers in bundled payment programs over the last five years? Per Clay Richards, CEO and president of naviHealth, a Cardinal Health company, they are: 1. Don’t underestimate the importance of data analytics. Hospitals need to compare their data against national and regional benchmarks to identify high-cost areas that can benefit from clinical interventions and care redesign. This includes drilling into the data not only by episode, but also by individual physician. A successful game plan for the program begins with the data.

2. Hospital leadership must be committed to true change management, and must demonstrate a willingness to think outside the box in terms of care improvement. Episodes of care should be designed holistically around the patient, which requires a mix of new methodologies and capabilities for hospitals – ones that demand an increasing focus on individualized care plans and post-discharge planning, with the goal of returning patients to the highest functional status while preventing unnecessary complications and readmissions.

3. H ospital leadership must understand that continuous process improvement takes time. They need to commit to high quality value-based care, and they need to evolve as BPCI Advanced continues to change.

will be identified by HCPCS codes. The Clinical Episode will end 90 days after the end of the Anchor Stay or the Anchor Procedure.

BPCI Advanced will initially include 29 inpatient and three outpatient “Clinical Episodes.” Participants selected to participate in the program will be held accountable for one or more Clinical Episodes, and may not add or drop such Clinical Episodes until Jan. 1, 2020.

Types of services included in a Clinical Episode are: • Physicians’ services • Inpatient or outpatient hospital services that comprise the Anchor Stay or Anchor Procedure • Other hospital outpatient services • Inpatient hospital readmission services • Long-term-care-hospital (LTCH) services • Inpatient rehabilitation facility services • Skilled nursing facility (SNF) services • Home health agency services • Clinical laboratory services • Durable medical equipment (DME) • Part B drugs • Hospice services CMS has selected seven quality measures for the BPCI Advanced Model. Two of them – “All-cause hospital readmission” and “Advance care plan” – will be required for all Clinical Episodes. The following five measures will only apply to select Clinical Episodes: • Perioperative care: Selection of prophylactic antibiotic.

• Hospital-level, risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty.

12

May 2018 | The Journal of Healthcare Contracting

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REIMBURSEMENT

• Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery.

• Excess days in acute care after hospitalization for acute myocardial infarction.

• AHRQ patient safety indicators, including pressure ulcer rate, in-hospital fall with hip

“This effectively is a stake in the ground for the continued growth of valuebased programs.”

– Clay Richards

fracture, iatrogenic pneumo-

Cracking the code “While we're not surprised BPCI was successful, the results of our partnerships as a risk-bearing BPCI convener have and continue to exceed expectations,” says Richards. “With the more than 50 hospital partners we're working with across the country, we've helped achieve more than $83 million in total annual

thorax rate, perioperative hemorrhage or he-

gross savings while improving the quality of care

matoma rate, postoperative acute kidney injury,

for patients. With the recent BPCI Advanced an-

postoperative respiratory failure, perioperative

nouncement, we're particularly encouraged by

pulmonary embolism or deep vein thrombosis,

CMS' emphasis on care redesign and tying perfor-

postoperative sepsis, postoperative wound

mance to more quality measures – measures that

dehiscence and unrecognized abdominopelvic

go beyond just ‘checking the box’ and that really

accidental puncture/laceration.

put the patient forward.

A new look BPCI and BPCI Advanced share a number of features. For example, both are voluntary programs, and both allow hospitals or physician group practices to assume responsibility for bundles of care.

However, BPCI Advanced diverges from BPCI in several ways: • BPCI Advanced establishes the first-ever outpatient episodes – percutaneous coronary intervention, cardiac defibrillator, or back and neck except spinal fusion – all of which are identified by a Healthcare Common Procedure Coding System, or HCPCS, code. Additional clinical episodes may be included in future model years.

• BPCI Advanced is an Advanced Alternative Payment Model (Advanced APM) under the

14

Quality Payment Program. In addition to the potential for participants to receive payments under the model, eligible clinicians who meet threshold levels of participation in BPCI Advanced for a year will receive a 5-percent APM incentive payment under the Quality Payment Program (available for payment years from 2019 through 2024).

• BPCI Advanced will take into account patient case mix. Preliminary target prices will be provided in advance of the first performance period of each model year and will be adjusted during the semi-annual reconciliation process to calculate a final target price that reflects patient case mix during the applicable performance period.

May 2018 | The Journal of Healthcare Contracting

REIMBURSEMENT

“BPCI provides the unique opportunity

The 32 Clinical Episodes

for providers to drive change and improve-

The 29 inpatient Clinical Episodes in BPCI Advanced are: 1. D isorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis 2. Acute myocardial infarction 3. Back & neck except spinal fusion 4. Cardiac arrhythmia 5. Cardiac defibrillator 6. Cardiac valve 7. Cellulitis 8. Cervical spinal fusion 9. COPD, bronchitis, asthma 10. Combined anterior posterior spinal fusion 11. Congestive heart failure 12. Coronary artery bypass graft 13. D ouble joint replacement of the lower extremity 14. Fractures of the femur and hip or pelvis 15. Gastrointestinal hemorrhage 16. Gastrointestinal obstruction 17. Hip & femur procedures except major joint 18. L ower extremity/humerus procedure except hip, foot, femur 19. Major bowel procedure 20. Major joint replacement of the lower extremity 21. Major joint replacement of the upper extremity 22. Pacemaker 23. Percutaneous coronary intervention 24. Renal failure 25. Sepsis 26. Simple pneumonia and respiratory infections 27. Spinal fusion (non-cervical) 28. Stroke 29. Urinary tract infection

ever the arrangement, we’ve seen a real

The three outpatient Clinical Episodes are: 1. Percutaneous coronary intervention (PCI) 2. Cardiac defibrillator 3. Back and neck (except spinal fusion)

ments in healthcare,” he continues. “Whatcoalescence around a program like BPCI – one that is shared across the continuum by all providers in that we can continue to do better in patient outcomes, patient quality and in driving value.”

Says Hiller, “We have witnessed incredible success for those organizations who ‘crack the code’ for bundled payments,

both in medical bundles and surgical bundles, thus proving the bundled-payment model is a triple win for hospitals, physicians and patients. Some providers find the concepts of bundles to be the way care should be coordinated across the continuum – applying many bundled paymentlike concepts to other service lines.

“The disappointment may come for those organizations that are unable to gain leadership and organizational alignment in time to succeed and make a difference in their bundled payment program. Timing is everything and is crucial to success.”

16

May 2018 | The Journal of Healthcare Contracting

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REIMBURSEMENT

Bundled payments programs: Not a side project Bundled payment programs are not for the weak of heart or for health systems lacking solid leadership.

A study in the Journal of the American Medical Association in January reported that only 12 percent of eligible hospitals signed up for the voluntary BPCI program, and 47 percent of them dropped out within two years.

“Successful “The BPCI national hospitals and trend factor (which has been modified for BPCI those that appear Advanced) continued to most ready for create downward comBPCI Advanced pression on the target prichave made an es in the later years of BPCI,” organizational says Mark Hiller, vice presicommitment to dent of bundled payment value-based care services at Premier. “These and have worked diminishing returns were to foster a culture most likely one of the prichange, where mary factors related to an care is managed early departure.

“In addition, internal and coordinated across the organizational alignment is critical. There are nega- recovery journey.” tive implications for a hos– Gina Bruno pital if bundled payments are treated as a side ‘project’ versus a dedicated, systemwide endeavor. We have found that some of these factors contribute to a hospital’s success compared to those that drop out of the program.”

Says Clay Richards, CEO and president, naviHealth, “Many hospitals did not choose to participate in BPCI due to the nature of uncertainty and perhaps the perceived inability to influence post-acute outcomes. For those hospitals that did participate, several may have jumped into the program not understanding the full scope of participation, or perhaps engaged without convener support, or without adequate preparation to implement the processes and capabilities required to impact post-acute outcomes.

18

“In our experience, those health systems that remained in the program have seen steadily increasing results as adoption of care redesign has increased and alignment of stakeholders across the continuum has improved. CMS has solved some of the pricing uncertainty and transparency concerns that are present in BPCI. There’s also an aspect of time and care delivery trending toward value-based care. As payers continue to incentivize this type of care, there will be greater and greater uptake.”

Readiness for change A readiness for change is perhaps the most significant predictor of a health system’s success with bundled payment programs, says Gina Bruno, vice president, clinical strategy, naviHealth.

“Successful hospitals and those that appear most ready for BPCI Advanced have made an organizational commitment to value-based care and have worked to foster a culture change, where care is managed and coordinated across the recovery journey.”

They have invested in clinical decision support technology as well as clinical resources – including care coordinators or care navigators – to drive more informed decisions about post-acute care, and to monitor patients’ post-acute progress, says Bruno. In addition, they are selecting post-acute providers with consistently high outcomes, with the staff and resources to meet the needs of their patients, and a willingness to work collaboratively to use data to monitor performance.

That said, patient choice remains paramount; patients and their families are the ultimate decision-makers about who will provide their postacute care, she says.

“It’s not an easy task. Many systems have taken months if not years to formulate these processes and all that comes with it. But they realize that there is benefit to doing this work beyond just Medicare and BPCI.”

May 2018 | The Journal of Healthcare Contracting

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INFECTION PREVENTION

Contact Precautions:

When to Stop.

According to the guidance document, hospital personnel should weigh how much time has elapsed since the last positive culture to determine if contact transmission is likely. The guidance also advises on patient characteristics that

When is it safe for hospitals to discontinue contact pre-

20

could determine the duration of care.

cautions – gloves, gowns, masks, etc. – for patients with multi-

For Clostridium difficile infections (CDIs)

drug-resistant bacteria? The Society for Healthcare Epidemiolo-

specifically, the recommendation is to

gy of America published new guidance on the topic in January,

continue contact precautions for at least

in Infection Control and Hospital Epidemiology.

48 hours after the resolution of diarrhea,

"Because of the virulent nature of multidrug-resistant infec-

and to consider extending if CDI rates are

tions and C. difficile infections, hospitals should consider estab-

elevated despite infection prevention

lishing policies on the duration of contact precautions to safely

and control measures.

care for patients and prevent spread of these bacteria," said David

Insufficient evidence exists to make

Banach, M.D., MPH, an author of the study, and hospital epide-

a formal recommendation on whether

miologist at University of Connecticut Health Center. "Unfortu-

patients with CDI should be placed on

nately, current guidelines on contact precautions are incomplete

contact precautions if readmitted to the

in describing how long these protocols should be maintained.”

hospital, according to SHEA. May 2018 | The Journal of Healthcare Contracting

ASSISTED LIVING

• State Medicaid agencies varied in what types of critical incidents they monitored. All states identified physical, emotional, or sexual abuse as a critical incident. A number of states failed to identify other incidents that may indicate potential harm or neglect, such as medication errors (seven states) and unexplained death (three states).

• State Medicaid agencies varied in whether they made information on critical incidents and other key information available to the public. Thirtyfour states made critical incident information available to the public by phone, website, or in person, while another 14 states did not have such

In the Dark State Medicaid agencies fail to report critical information about assisted living services

information available at all.

GAO recommended that the Centers for Medicare & Medicaid Services clarify state requirements for reporting program deficiencies and require annual reporting of critical incidents. HHS

State Medicaid agencies covering assisted living ser-

said it would consider annual reporting

vices are failing to report some critical information about bene-

requirements for critical incidents after

ficiaries’ health and welfare, according to the United States Gov-

completing an ongoing review.

ernment Accountability Office (GAO), which released a report in January. According to the GAO: • Twenty-six state Medicaid agencies could not report to GAO

State Medicaid agencies in 48 states that covered assisted living services reported spending more than $10 billion (federal

the number of critical incidents that occurred in assisted

and state) on such services in 2014, accord-

living facilities, citing reasons including the inability to track

ing to the GAO. These 48 states reported

incidents by provider type (nine states), lack of a system to

covering these services for more than

collect critical incidents (nine states), and lack of a system

330,000 beneficiaries through more than

that could identify Medicaid beneficiaries (five states).

130 different programs.

Editor’s note: The GAO report – Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare Is Needed – is online at https://www.gao.gov/assets/690/689302.pdf.

22

May 2018 | The Journal of Healthcare Contracting

Better, faster.

It’s what we want for patients.

What about your clinicians?

Connecting vital signs monitors to the EMR has been shown to: Y

Reduce errors caused by manual processes1

Y

Save clinicians time by removing manual documentation steps2

Y

Increase clinical time spent on value-added care3

40

1

Reduction in minutes of vital signs data latency in the EMR after connecting vital signs4

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1 CIN: Computers, Informatics, Nursing: Eliminating Errors in Vital Signs Documentation, FIELER, VICKIE K. PhD, RN, AOCN; JAGLOWSKI, THOMAS BSN, RN; RICHARDS, KAREN DNP, RN, NE-BC, 2013. The paper vital signs recording had an error rate of 18.75%.

2 JHIM FALL 2010 Volume 24:Number 4, Vital Time Savings: Evaluating the Use of an Automated Vital Signs Documentation System on a Medical/Surgical Unit 3 Going One Step Further at Scott & White Medical Center—Temple: Eliminating manual vital signs documentation to prioritize value-added care. 2017 Welch Allyn. www.welchallyn.com 4 CareAware® VitalsLink: Eliminating Data Latency & Manual Documentation at Naples Hospital. Prepared by Cerner, 2013. © 2017 Welch Allyn

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