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Truth Be Told: What CMS Doesn’t Tell You About the Medicare Shared Savings Program

Posted by Matthew Smith on Sep 28, 2016 11:10:56 AM

By Andy McNerney, Manager, GE Healthcare Camden Group


When the Centers for Medicare & Medicaid Services ("CMS") launched its Medicare Shared Savings Program ("MSSP") in 2012, CMS leveraged the upside, risk only-design and the opportunity to be a care model redesign champion. It also intended to lead the market in value-based care delivery as a way to entice ACOs to join the program. Four years and 539 accepted MSSP ACOs later, CMS released its most recent set of performance results for the 80 percent of ACOs that have survived the program.

While savings of more than $429 million and overall quality improvement sounds like cause for celebration, the real story begins by acknowledging that program success doesn’t come easily and requires hard and transformative work…just ask the almost 70 percent (n=272) of MSSP participants who failed to achieve a shared savings distribution. Even for those participants that did achieve program savings, it is likely that the set-up and operating costs associated with the ACO program threatened bottom line financial success…today. But care transformation is not just about today’s bottom line, is it? Program veterans, or those who have participated for more than one Performance Year, have shown that it takes years to truly make an impact on cost and quality. The rest of the story will be written by their continued success as they gain a strategic advantage and encourage other providers to invest in their own transformation.

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If CMS Isn’t Telling the Whole Story, Define and Measure Your Own Success!

Participation in the MSSP is not only an opportunity to impact select quality metrics and recuperate some dollars lost as a result of reduced unnecessary utilization. It is a long-term strategic play to prepare for the not so distant future when up- and down-side risk taking will be the norm, not the exception. The data provided from CMS through the MSSP program is neither real-time nor risk-adjusted, making it extremely difficult for ACOs to assess their performance. In addition, the influx of participants makes it challenging to track and trend an ever-moving target. Furthermore, performance on quality measures is not released to the ACOs until Quarter 2 of the following performance year.

This leaves the ACO limited time to review performance, establish initiatives, and implement efforts to improve outcomes. ACOs need to develop a mechanism by which they can continuously monitor overall cost of care and performance on the established quality measures so that they are not relying on CMS to report on their progress. Instead, continuous process improvement and measurement needs to be the new normal in preparation for a time when CMS will not be the only value-based contract in place. The amount of shared savings achieved, the level of patient satisfaction, and the quality outcomes delivered at the end of each Performance Year should not be a surprise, but all too often it is!

The Focus On Quality Should Go Beyond MSSP Attributed Lives!

The overall quality improvement shown by the MSSP ACOs indicates a program-wide commitment to improved health outcomes that should be applauded. These measures focus on patient satisfaction, reduction in avoidable utilization, preventive care, and evidence-based protocols for at-risk populations. Successful performance on many of these measures requires substantial data aggregation and analysis and proactive outreach to MSSP ACO patients. Where many ACOs falter is by laser-focusing on only the MSSP population; those beneficiaries assigned to the MSSP receive proactive preventative care while other patients are overlooked.  While this can be a successful short-term strategy (particularly when resources are limited or information systems have not yet have matured), operationalizing it is a challenge and this approach will not position the organization for long-term success.

Quality outcomes initiatives should be inclusive of all patients, regardless of payer, to demonstrate that your model of care can be scaled and to attract similar shared savings arrangements beyond CMS. The bigger problem is that care delivery does not just change for a given population and organizations are realizing that other payers are benefiting from their performance improvement efforts, which causes barriers to engage these providers in value-based contracting because the organization is producing results that are benefiting the payer without the compensation.

In 2015, CMS set a goal of having 50 percent of Medicare payments made through alternative payment models by 2018. Providers have responded through strong participation in programs such as MSSP, Pioneer ACO, and Bundled Payments and indications are that value-based payments will become the standard. If your organization embraces a value-based world, then program participation can be a good step towards building the necessary muscle. But only if you make a full organization wide commitment to the cultural change required to support care model redesign and do so with a customized definition of success; because unsuccessful participation may be even more costly to an organization than no participation at all.

Organizations who don’t take the time to invest in the appropriate care coordination resources will find that they have spent money on ACO staff, slightly reduced inpatient utilization (and therefore revenue), and receive no shared savings distribution to offset these costs. This can be a very frustrating result, leading to dissatisfaction with the program and disillusionment with care coordination. So, jump in! But don’t leave the necessary people, data, or innovation behind. 


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Mr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com

 

 

 

Topics: MSSP, CMS, MSSP ACO, Andy McNerney

Preparing for Episode Payment Models—Next Up: Cardiac Care Bundled Payments

Posted by Matthew Smith on Aug 15, 2016 9:53:21 AM

By Andy McNerney, Manager, GE Healthcare Camden Group

CMS’s newly proposed Episode Payment Models (“EPM”), focused on cardiac care, is the second major push to mandate the national adoption of bundled payments’ in recent years. Perhaps your organization was spared as you watched 67 other markets forced to bundle joint replacements. If your reaction was only to feel lucky that you dodged the swipe of our government’s hand instead of better preparing your service lines for episode based care delivery, then it’s time to organize regardless of which markets are selected this time around. 

These cardiac mandates have been proposed under the umbrella of EPMs, and participation will qualify physicians towards Advanced Alternative Payment Models (“APMs”) credit suggests CMS’ intention to roll out more. Although a cardiac episode presents very different challenges than a joint replacement, the way your service line approaches the episode care design, standardization, and monitoring process is very similar. If you haven’t already started enabling your service lines to execute on a bundle, don’t wait for a government dart to land in your market to do so. Instead, start developing work teams responsible to design and standardize processes across the pre-acute, inpatient, and post-acute setting as well as work teams dedicated to the reporting and monitoring of outcomes and engagement of patients across the entire episode.

The Proposed Model

Three major components make up the mandatory EPM proposal:

1. Cardiac Bundles: Inpatient admissions will be paid under a bundled payment for Acute Myocardial Infarction (“AMI”) episodes and Coronary Artery Bypass Graft (“CABG”) episodes for the next 5 years as follows:

  • Episode length: 90 days post-discharge
  • Mandated Markets: 98 random markets (rural markets excluded)
  • Downside Risks and Gains: Phased in over time and max out at 20 percent in the final years
  • Target Price: Weighted to hospitals’ historical performance in year 1 and transitions to one regional price in year 5
  • Quality and patient satisfaction scores influence financial gain or downside risk

2. Cardiac Rehabilitation (“CR”) Incentives: CMS will incent cardiac rehabilitation services utilization post-discharge within the 90-day episode period through retrospective payments as follows:

  • First 11 CR Services post-discharge from CABG or AMI admission: $25
  • Remaining CR Services in 90-Day Episode: $175

3. CJR Addition: Surgery for Hip Fractures was added to the current CJR mandate and will only immediately affect those hospitals in CJR mandated regions.

Not surprisingly, the proposed cardiac bundles are designed with very similar objectives to the CJR bundles: reduce unnecessary utilization such as readmissions, incent discharge placement to the appropriate care setting, promote care coordination across providers, and improve quality through care model design and standardization. As such, organizations embracing this cross-continuum care delivery work for the first time should start by establishing work groups that represent the following four areas:

  • Inpatient Clinical Redesign: While some patients present as non-emergent cases, many are through the emergency department when episode expectations can’t be set in advance, as is done with pre-surgical joint placement classes. These cardiac episodes contain both surgical and medical care making physician engagement even more important. Form a work group now that identifies opportunities to improve quality and develop a standardized care approach. Consider the following representatives: cardiovascular surgeons, cardiologists, hospitalists, case managers, social workers, operating room leadership, supply and implant purchasers, emergency room physicians, and a strong physician lead driving change.
  • Post-Acute Care: Similar to CJR, a work groups’ time should be spent standardizing discharge placement protocols and identifying preferred providers (SNF, HH, IRF, Cardiac Rehab providers, and others) who commit to sharing data, adhering to best practice protocols, and meeting quality requirements. Much more important for cardiac bundles will be transitioning patients back to OP partners and processes dedicated to managing the chronic conditions that led to the original admission. Consider the following representatives: Post-acute care managers, SNFists, Cardiac Rehab clinicians, inpatient case managers, cardiac services line leaders, and other care coordinators.
  • Quality and Reporting: Monitoring your bundle performance as real-time as possible and ahead of the quarterly report from CMS will keep your care teams engaged and promote a culture of continuous improvement. Utilize representatives from finance and data / analytics to research dashboards and tools that help identify care delivery and cost variation and allow care coordinators to identify and track bundle patients in your system.
  • Patient Engagement: One major variable differs greatly to the CJR bundle—the patient population. Unlike an elective joint patient, this population has greater co-existing chronic conditions and will naturally have more unplanned services and complications which make achieving your objectives more unpredictable. Successfully engaging patients can make the difference and justifies the need for establishing a patient engagement work group. This work group should take a more social view and identify programs and tools to assist with adherence to treatments and medication management, compliance with Cardiac Rehab care plan and follow-up appointments, adherence to dietary and nutrition regimes, and social support services. This group may be an extension of other population health initiatives identifying high risk patients through risk assessment tools and empowers them with tactics and technologies to manage their recovery and prevention.

We recognize that resources are scarce, competing initiatives are many, and establishing work groups and initiatives without an actual mandate or direct incentive can be a tough sell. If you are not able to organize your operations and select service lines around the above work teams for the simple reason that it’s best for patients in your community, then do so under the assumption that bundles are here to stay, and the works needs to get done to succeed within them.    

Cardiac Care Bundled Payments


mcnerney.jpgMr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com 

 

 

 

Topics: Bundled Payments, CMS, Andy McNerney, Cardiac Care, Episode Payment Models

Three Prep Tips for Hospitals Preparing for CMS’ CJR Model

Posted by Matthew Smith on May 24, 2016 11:00:29 AM

Via Managed Healthcare Executive

April 1 marked the start of the CMS Comprehensive Care for Joint Replacement ("CJR") model, which the government agency hopes will support better and more efficient care for its beneficiaries undergoing hip and knee replacement surgeries, the most common surgeries among Medicare patients.

According to CMS, the rate of complications such as infections or implant failures can be more than three times as high at some facilities than at others—and that leads to hospital readmissions.

In 2014, there were more than 400,000 hip and knee replacement procedures, which cost $7 billion in hospitalizations alone. The cost to the government agency was an average of $16,500 to $33,000 for surgery, hospitalization, and recovery across geographic areas in this time period.

With the CJR model, participating hospitals are held financially responsible for the quality and cost of the surgical procedure, which starts when the patient is admitted and ends 90 days after their discharge from the hospital.

Prep tip 1: Focus on post-acute recovery decision-making

The biggest opportunity for hospitals and health systems involved in the CJR model is in the post-acute recovery space, says Andrew McNerney, consulting manager with GE Healthcare Camden Group.

To continue reading this article on the Managed Healthcare Executive website, please click the button below. You will be directed immediately to the full article (no form required).

CJR, Bundled Payments


mcnerney.jpgMr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com

 

 

Topics: Bundled Payments, CMS, CJR, Andy McNerney

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