The Centers for Medicare and Medicaid Services (CMS) is adopting new payment policies that will rapidly shift current reimbursement models that reward volume to alternative models designed to reward value and care coordination. These reforms also expand existing value-based purchasing programs that pay incentives or impose penalties based on performance in selected quality and efficiency measures.
One alternative model, bundled payments, will reimburse hospitals for services provided to patients during an episode of care. An episode starts with a hospitalization and includes services for a period of 30, 60, or 90 days post-discharge. The bundled payment covers facility and professional services delivered during the index hospitalization and post-discharge period, including hospital readmissions, skilled nursing facility, and home health care. To prepare for bundled payments, hospitals must analyze their historical performance and details about the services patients received during the episode. However, CMS does not supply hospitals with basic information necessary to accomplish this important step.
Payments for post-acute care, such as skilled nursing facility and home health care services, account for 73 percent of the geographic variation in Medicare payments per beneficiary, suggesting that a significant portion of these payments may be unnecessary. Bundled payments present an opportunity to reduce unnecessary post-acute care services and Medicare spending.
Medicare Bundled Payment Programs
Medicare launched Bundled Payments for Care Improvement (BPCI) in 2011, a voluntary program giving health care organizations an opportunity to choose episode-based reimbursement for up to 48 different patient populations. More recently, it implemented a mandatory episode payment program for hospitals in selected geographic areas that perform hip and knee replacements, called Comprehensive Care for Joint Replacement (CCJR).
Both programs define populations based on Medicare diagnosis-related groups (DRG), a system Medicare currently employs to classify inpatients by type of condition or surgical procedure and to determine hospital reimbursement. In many ways, episode-based reimbursement can be viewed as an extension of the DRG-based method, which put hospitals at financial risk for the costs of inpatient hospital care. Episode payments will put hospitals at financial risk for not only for the index hospitalization but also for physician and post-discharge services. Currently, high payments to outside providers for post-discharge care do not affect the hospital bottom line, but under episode-based reimbursement, high payments to outside organizations will become a drag on a hospital's financial performance.
The health services literature on episode-based payment has focused largely on the perspective of policymakers, not hospitals that must find ways to adapt their financial and patient care models. Hospitals are in the early stages of both understanding the implications of bundled payments and defining specific programs to most effectively respond to the new demands. Most hospitals have little experience with bundled payments.
Only about 7 percent of acute-care hospitals nationwide enrolled in the first phase of BPCI to obtain Medicare claims data and explore their historical episode payments for 48 different patient populations. Less than 4 percent of hospitals participated in the second phase and selected populations for which they accepted financial risk for episode payments that exceeded a target. Hospitals enrolled in BPCI tended to be large academic medical centers with an existing affiliation with post-acute care providers and were "more equipped than others to engage in innovative payment and delivery approaches…"
To be successful under the new payment model, hospitals must manage both costs associated with the services they provide during the index hospitalization (costs of inpatient facility services such as nursing, imaging, medications, and operating room) and Medicare episode payments, particularly for physician and post-discharge services delivered by outside providers.
How Hospitals Can Prepare for Bundled Payments
Initial steps in the process of preparing for bundled payments include the identification of populations with high index hospital costs and post-discharge payments as well as analyses of the specific root causes that will form the basis for changing processes of care. These steps underscore the importance of health care data and analytics.
Costs of care in the inpatient setting and payments for post-discharge services are heavily influenced by quality and coordination of care. By examining inpatient populations with significant variation in costs and poor financial margins, hospitals may discover variation in both clinical practice and patient outcomes. Similarly, identifying conditions with high episode payments can expose post-discharge complications, poor coordination of care, and potential unnecessary use of services.
A unified analysis of an episode of care requires detailed information for both the index hospitalization and post-discharge period. Unfortunately, no single source of information for an episode of care provides sufficient details for both components.
The inability to obtain information spanning both inpatient and post-discharge services is a significant barrier to hospitals making preparations for moving to an episode-based payment system.
Hospitals Lack Access To Critical Sources Of Data
Hospitals require information from several sources:
- Hospital billing and cost accounting systems to select patient populations and analyze costs of hospital services and financial margins;
- Electronic medical records (EMR) to examine both variation in practice (use of tests and treatments) and incidence of complications (e.g., postoperative infections); and,
- Episode payments to benchmark performance for populations and analyze payments for services provided during the episode, including those delivered by outside providers.
Most hospitals use billing and cost accounting systems. Some have successfully integrated these sources with clinical data from the EMR to evaluate and drive improvements in efficiency and quality of care for hospitalized patients. By contrast, most hospitals lack useful information about episodes of care for physician and post-discharge services.
CMS currently supplies episode payments to hospitals as a measure of efficiency under the Hospital Value-Based Purchasing program, called Medicare Spending per Beneficiary (MSPB). Unfortunately, these data do not provide details essential to understanding the drivers of episode-based payments.
Hospitals can use MSPB data to identify populations, defined by DRG, where their episode payments are higher than the national average. However, identification of populations is only the first step. Other benchmarks, to which hospitals do not have access, are required to identify the types of services that are driving the higher payments (e.g., skilled nursing facility). Hospitals also need access to Medicare claims that provide details about potentially preventable complications or unnecessary services occurring post-discharge.
Without this kind of information, hospitals cannot easily identify the factors contributing to higher payments or specify interventions that may improve performance.
Several private sector experiments with bundled payment have emerged, some of which include Medicare populations. Blue Cross Blue Shield of Michigan (BCBSM) established the Michigan Value Collaborative (MVC) to deliver episode payment information for a small BCBSM PPO and a much larger Medicare population to over 50 hospitals statewide. MVC offers hospitals a potential means to prepare for new bundled payments, but is currently constrained because CMS will not permit MVC to share detailed Medicare claims data.
Nationally, the American Medical Group Association and American Hospital Association have lobbied Congress to make Medicare claims data more broadly available to providers to drive improvements in quality and efficiency. The effect of these appeals on CMS policies and plans for releasing Medicare data are not yet clear.
Under the CCJR program, Medicare provides hospitals with detailed historical claims data for their joint replacement patients from the index hospitalization through 90 days post-discharge — detailed information critical to evaluating clinical and financial performance. However, these details are provided only concurrently with implementation of the program, giving hospitals little time to organize, analyze, and use these data to identify opportunities and risks.
What Medicare Can Do
The most effective step CMS could take toward helping hospitals prepare for bundled payments would be to make historical Medicare episode payment data for their patient populations available to each acute care hospital. The data could be organized into three levels, each progressively more detailed, to allow hospitals to select and analyze populations with high episode payments:
- Total price-standardized and risk-adjusted payments for episodes, defined by clinical groupings of DRGs, compared to regional and national benchmarks.
- Payments for categories of services in each of the DRG-defined episodes, including the index hospitalization and specific types of post-discharge services, compared to regional and national benchmarks.
- Detailed claims within each service category of the episode, to facilitate the analysis of factors that contributed to higher payments and development of strategies (e.g., developing partnerships with key post-acute care providers) and interventions to improve performance.
Broad access to useful Medicare information will reduce the competitive advantage enjoyed by those hospitals that join state or regional collaborative data sharing programs or that are better equipped to participate in innovation models like BPCI. Furthermore, it will help acute-care hospitals, all of which participate in the Hospital Value-Based Purchasing program, improve their MSPB performance.
Bundled payments represent a sea change in reimbursement and management of patients across care settings. Hospitals face not only significant financial risk but also analytic challenges that are confounded by the lack of important data. CMS is moving quickly to adopt bundled payments, but should move just as quickly to deliver a health care data infrastructure to help hospitals succeed.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/1ToaTIX
No comments:
Post a Comment