by Jason McCormick Vice President, Partner Services at Fusion5
One of the first lessons I learned regarding bundled payments was that everyone had a different definition of the term. To some, bundled payments refer to the proactive payment for a set of services that are provided to a patient, while others may be more in line with the CMS definition of bundled payments, which refers to a retrospective review of performance compared to a target price. Regardless of your accepted definition, bundled payments are one of the mechanisms that are being used to reimburse providers for services rendered in an effort to reduce health care expenditures.
As with most anything in life, those that “get it” have an opportunity to be extremely successful and those that struggle with implementing and following through will fall another step behind. A well-designed plan can serve as the foundation for a successful bundled payment program and ensure that strategies are in place to address any complications. Here’s a list of the ten program elements that have proven to offer stability and helped maximize the financial opportunity that these types of programs offer.
1. Data Review – Usually this review is going to be based on claims data, but there is plenty available to identify opportunities. Not only does the data review help identify opportunities, it helps to identify those services or providers that are not delivering value or quality care.
2. Identify & Engage Preferred Provider Network – Once your review of data is complete, you will have a good idea of those providers that offer the quality of care you desire and what type of value they will bring to your program. Next step is to engage those providers to create a partnership network.
3. Establish Protocols & Clear Lines of Communication- Successful bundle programs are all about having protocols in place that can easily be followed. Open lines of communication will ensure that any variance from expected result is discussed and treatment plans addressed.
4. Identify Surgical Candidates Early- This element proves to be valuable time and time again, as there will be more time to prepare the patient and conduct the pre-surgery requirements, such as medical clearance. Early identification also helps plan patient needs once they move into the post-acute period.
5. Scheduling Prehab and Outpatient Physical Therapy – Pre-surgcal participation in a prehab program has shown to improve outcomes, as patients are taught exercises to increase range of motion and to maintain strength. Having outpatient appointments scheduled prior to surgery prevents patients from being overwhelmed with details the day after surgery.
6. Conduct Risk Assessment with Patient – Conducting a pre-surgical risk assessment allows for potential issues to be identified and addressed before surgery and before they require extensive or unplanned resources. Many issues can be dealt with in a medical management setting prior to surgery if they are identified early.
7. Setting Patient Expectations – This element may have the largest potential to impact cost and prevent last-minute decisions, which can lead to utilization of unplanned resources. Everyone associated with the patient from the time they are identified as surgical candidates should be involved in setting the patient’s expectations.
8. Managing Behaviors – If setting patient expectations is the most important factor, managing behaviors is the second. Program coordinators need to be prepared to manage the behaviors of everyone involved in the process, including the patients, physicians, and partnering post-acute facilities and/or service providers.
9. Care in the Post-Acute World – If the episode period for the bundled payment program extends past the surgical event, you have to be prepared to remain involved in the patient’s care once they move into the post-acute period. The post-acute period can include inpatient rehab facilities, skilled nursing facilities, transitional living, home health services, outpatient physical therapy services, or any other service provider.
10. Establish Strategies for Addressing Potential Readmissions – Regardless of the best-planned program, unfavorable outcomes will happen. Establishing strategies for how providers will deal with patient questions and/or concerns can prevent an unnecessary emergency room visit or a readmission that could have been addressed by answering a patient question.
These elements have proven to be extremely valuable in the creation and maintenance of bundled payment programs, both in inpatient and outpatient settings. While these elements may carry different weight in each type of bundled payment program, successful programs will have each of the elements in place to some degree. Regardless of ownership or management structure, implementing these elements is possible. The basic requirements will prove to be the building blocks that you can fall back on when things need to be reassessed.
This is the first in a series of articles that will provide additional thoughts and tactics on what can be accomplished by implementing each of these program elements. We will look into how each element can be added and what actions can be taken to ensure the element becomes a program fundamental. These fundamentals will help your practice take advantage of every model put in front of you and help you crush bundled payments.