5/24/2017 Bundled Payments for Care Improvement (BPCI) Initiative Healthcare Financial Management Association Cathy Ball, Director, Bundled Payments Initiative Lahey Clinical Performance Network (LCPN) June 2, 2017 DISCLAIMER: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Bundled Payments for Care Improvement (BPCI) Agenda 1. Introductions 2. Overview of Lahey BPCI Initiative 3. Implementing a Bundle 4. Lessons Learned/ Challenges/ Rewards 5. Questions a) Appendix: Commonly Used Acronyms 3 BPCI Overview: updated 7/26/2016 KC & LJ 1
5/24/2017 BPCI – Value-Based Payment Model • “Population Health” • ACA Legislation 2010 – Centers for Medicare and Medicaid Innovation (CMMI) • Pay for Value, not Volume with quality gaits 4 CMMI - Value Based Models • BPCI 1 – Five-year voluntary pilot initiative – 10/13/13 – 9/30/18 • Comprehensive Joint Replacement (CJR) – Mandatory – 4/1/16 – 12/31/2020 - 67 Metropolitan Service Areas (MSA) • Oncology Care Model (OCM) – 7/1/16 – 6/30/21 - Six month chemotherapy • Cardiac Bundle (AMI, PCI, & CABG) – Mandatory – Begins 10/1/17 - Medical treatment, procedures, and emphasis on cardiac rehab - Surgical Hip and Femur Fracture Treatment (SHFFT) - 98 Metropolitan Service Areas (MSA) • New Bundled Payments Model (TBD) 5 BPCI Overview: updated 7/26/2016 KC & LJ 2
5/24/2017 BPCI – Bundled Payments for Care Improvement CMS Aim: Better Health, Better Care, Lower Costs 1. Four different options offered by CMMI (Center for Medicare & Medicaid Innovation): – Model 1 – Retrospective Acute Care Hospital Only – Model 2 – Retrospective Acute Care Hospital Stay plus Post-Acute Care – Model 3 – Retrospective Post-Acute Care Only – Model 4 – Prospective Acute Care Hospital Stay Only 2. Model 2 post-acute timeframe can be 30, 60 or 90 days 3. Two years into the pilot, Models 1 & 4 are phasing out, Model 2 most popular and implementation model selected for mandatory bundles 4. Payments continue via PPS methodology during pilot episodic based payments (EPM) 6 Bundled Payments for Care Improvement (BPCI) • Current => Hospital and Physician services have adapted to a “DRG Mentality” where we manage cost for acute hospital stay: Acute hospitalization at Acute Discharge (~4.6 days) Lahey - Burlington (All inpatient cost, including OR time, supplies, and implants, post operative care, Inpatient and post op consults, rehab, CM) • Future => New model (Bundled Pymt, Model 2) – manage total continuum of care episode costs: Acute hospitalization at 90 days post-d/c (~94.6 days) Lahey - Burlington (Inpt Rehab, SNF, HHA, LTCH, PCP/Specialist, OP Appts, DME) • Current => Individual payments Future => One Bundled payment by care setting tied to quality 7 BPCI Overview: updated 7/26/2016 KC & LJ 3
5/24/2017 Bundled Payments for Care Improvement (BPCI) Red = CMS, voluntary pilot, at risk (LHMC only) Purple = CMS, mandatory, system-wide 7/1/17 • 48 pilot bundles – organized by service line Teal = Commercial bundle pilots (LHMC only) Diabetes/ Gastroenterology Infection Cardio Ortho Neuro Pulmonary Other Vascular / Colon/ Rectal Control • Acute Myocardial • Double Joint • Back & Neck • Amputation • Esophagitis, • Chronic • Cellulitis • Red Blood Infarction (AMI) Replacement – LE (except spinal Gastroenteritis, & Obstructive Cell • Sepsis • Diabetes * fusion) other Dig Disorders Pulmonary Disorders • Atherosclerosis • Fractures – Femur and Disease (COPD) * • Urinary Hip/ Pelvis • Cervical Spinal • Gastrointestinal • Medical • Auto-implantable Tract Fusion Hemorrhage Peripheral Cardiac Defibrillator • Hip & Femur Proc Infection • Other Respiratory Vascular (except major jt.) • Combined Ant/ • Gastrointestinal • CABG/ CABG Disorders • Simple Pneumonia Post Spinal Fusion Obstruction • Lower Extremity & & Respiratory • Cardiac Arrhythmia • Nutritional & • Complex non- • Major Bowel Humerus Procedure Infections Metabolic Cervical Spinal • Cardiac Defibrillator (ex. hip, foot & femur) Disorders Fusion • Cardiac Valve • Major Joint Lower • Other Vascular • Spinal Fusion Extremity TJA CJR • Chest Pain Surgery (non-Cervical) • Major Joint Upper • Congestive Heart • Renal Failure • Stroke Extremity Failure (CHF) * • Transient Ischemia • Medical Non-infectious • Pacemaker Device Orthopaedic Rep/ Revision • Other Knee Procedures • Pacemaker • Removal of • PCI Orthopaedic Devices • Revision of Hip or Knee • Syncope & Collapse * Commonly followed by ACO 8 BPCI – Project Milestones 9 BPCI Overview: updated 7/26/2016 KC & LJ 4
5/24/2017 BPCI – Implementing A Bundle • Steering Committee – Project Champion, Project Manager, Home Dept. • Project Charter - Problem Statement - Metrics - Aim, Goals - Risks, Barriers/Constraints - Resources - Milestones/ Timeline • Organizational Readiness Assessment • Bundle Selection - strategic alignment - ~100 episodes annually - current performance 10 BPCI – LHS Bundle Pilot Infrastructure • Program Director - Project Manager (1 FTE for 2 bundles); Case Managers based on bundle volume • BPCI Convener - Public Policy/Issues Forum/ CMS Liaison - Project Manager Roundtables - Data Analytics/ Reports/ Interpretation - Advisory Meetings/ Services - Training Resources • Administrative Workgroup – clinical, finance, legal, HIM, supply chain, care coordination, quality, IT • Multidisciplinary, multi-setting team per bundle • Community Resource Network – services not provided by hospital/ health system but integral to patient’s episode of care (anchor stay + 90 days) - Pre-admission for elective bundles: Preventative services, health optimization, patient education - Post-acute discharge: Acute Inpt Rehab, SNFs, Home Health, OP Svcs, Transportation, Hospice, Assisted Living Communities, Long-term Acute Care organizations, Meals on Wheels, Elder/ Senior Centers, Social Work resources, etc. 11 BPCI Overview: updated 7/26/2016 KC & LJ 5
5/24/2017 BPCI – Multidisciplinary Bundle Teams Team Membership Subject Matter Experts (as needed) • Physician Champion • Lab, Radiology • Nurse Champion • HIM, CDI • Service Line Director (SLD) • Surgical Services, PACU • Case Management • OR Scheduling • Rehabilitation Services (PT, OT, & ST) • Hospitalist • Pharmacy • Nutrition • Hospitalist • IT • Nutrition • Legal • Amb Clinic and Inpt PAs, NPs • Quality • Patient Representative • Risk Management • Post-acute Representatives • Finance, Supply Chain 12 BPCI – Business Process Re-engineering 13 BPCI Overview: updated 7/26/2016 KC & LJ 6
5/24/2017 BPCI – Resulting Improvements • Pre-op patient education class (TJA); Inpt education class (CABG) • SNF 3-day waiver • Patient Compact • Standard Treatment Protocols across settings (anti-coag, blood mgmt, etc.) • Wound dressing pilot – 7-day dressing Pilot 3/2014; hospital-wide 12/2014 • Prescriptions filled as leaving hospital for home – Pilot 6/9/14; Sun 6/2016 • Insurance Authorization delays in discharge/ prescription filling • One number to call with questions 24/7 • Accelerated Ambulation – starts in PACU • Working DRG (CDI Team) and Estimated discharge date (new) • Readmits due to dehydration - Major Bowel, Transplant (new) • Lahey Care Link for post-acute organization access to test results (new) 14 BPCI – Data Analytics is Crucial Before Pilot Adoption • Internal acute cost and quality data metrics only • No post-acute provider utilization data beyond first d/c disposition location • No acute or post-acute benchmarks for comparison • No trending of current costs, LOS, or outcomes across care continuum After Pilot Adoption • Provided with mock reconciliation estimates to trend performance • Verify all bundle patients & identify outliers, readmissions, ED visits, etc. • Identification of high-level practice variations across providers • ID post-acute services utilized, LOS, & costs across 90-day episode • High-level pricing benchmarks nationally and within the state 15 BPCI Overview: updated 7/26/2016 KC & LJ 7
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