1.800.360.0603

GE Healthcare Camden Group Insights Blog

Facing Bundled Payments

Posted by Matthew Smith on Apr 20, 2017 11:05:07 AM

By Dominic Foscato, Vice President, GE Healthcare Camden Group

Change in reimbursement isn’t waiting for tomorrow. It’s happening right now. Rather than paying for each procedure and office visit, government and private health plans are moving toward a payment model based on the health of an organization’s patient population. During this transition, an organization’s success depends on its ability to manage a variety of payment models.

Health care organizations must successfully administer these payment models — which continue to evolve and grow more complex —while optimizing quality, outcomes and patient satisfaction. In short, they must manage “fusion reimbursement” or risk significant cuts in revenue.

Clinical Integration, Clinically Integrated Networks

Reprinted with permission from the February 2016 issue of Trustee magazine, vol. 69, no. 2. © Copyright 2016 by Health Forum Inc. Permission granted for digital use only

Topics: Bundled Payments, Value-Based Payments, Alternative Payment Models, Dominic Foscato

Evolving Physician Reimbursement Structures: Moving the Medical Group to Value-Based Success

Posted by Matthew Smith on May 19, 2016 10:17:08 AM

By Cami Hawkins, MHA, Manager, GE Healthcare Camden Group (originally published in Journal of Healthcare Management, May-June, 2016)

Now that the Medicare Sustainable Growth Rate ("SGR") formula has been repealed, physicians and other providers must prepare for the Merit-Based Incentive Payment System ("MIPS"). This article addresses several important questions about evolving physician reimbursement structures and provides guidance on how to succeed under the new programs.

With the passage of the Medicare Access and CHIP Reauthorization Act, what changes can physicians expect with regard to payment incentive models?

Repeal the Medicare SGR formula and passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are bringing about significant changes to the Medicare physician fee schedule and reimbursement methodology (Centers for Medicare and Medicaid Services ("CMS"), 2015). MACRA established annual positive or flat fee updates for ten years and implemented a two-track fee update thereafter. In addition, MACRA created MIPS and consolidated the current Medicare fee-for-service incentive initiatives. The law also provides a mechanism for physicians to participate in alternative payment methods, including the patient-centered medical home model and others to be defined. In repealing the SGR and passing the MACRA, Congress's intent was to move away from the fee-for-service payment methodology and toward a value-based payment system.

To continue reading, please download a PDF version of this article by clicking the button below. You will be directed immediately to the full article (no form required).

Value-Based Success


Hawkins_headshot.png

Ms. Hawkins is a manager with GE Healthcare Camden Group and has more than 20 years of experience in the healthcare provider sector as a management consultant. She specializes in the areas of practice operations, contract negotiations, benefits administration, reimbursement management, and market development. Ms. Hawkins assists a wide range of provider organizations, healthcare systems, and independent and employed physician groups with addressing issues impacting their overall performance and competitive positioning. Her key areas of expertise include strategic planning, population health strategy, and hospital/physician integrations. She may be reached at cami.hawkins@ge.com.

Topics: CMS, MACRA, Value-Based Payments, Cami Hawkins, MIPS, Physician Reimursement, Value-Based Success

A Business Plan of Operational Efficiency for a Value-Based World

Posted by Matthew Smith on May 17, 2016 10:34:14 AM

By Brandon Klar, MHSA, Senior Manager, GE Healthcare Camden Group

As health care continues its rapid evolution toward value-based reimbursement, health system leaders face escalating pressure to reduce their cost structure and enhance their value propositions. For many, the solution is to join forces with another provider through a formal partnership agreement. 

But once a new partnership has cleared the planning hurdle and avoided early pitfalls, it still faces a big challenge. How do you make sure the combined system achieves the full benefits of operational integration?

Our experience with providers nationwide has indicated that successful healthcare partnerships rely on one indispensable tool — a business plan of operational efficiency ("BPOE"). A detailed BPOE helps partnering organizations achieve the large-scale cost reductions necessary for value-based care and declining reimbursement.

The Business Plan of Operational Efficiency

A health system BPOE is a comprehensive, action-oriented system integration plan. It is designed by and for organizations that are forming a single corporate structure strategically and operationally. Simply defined, a BPOE is a road map for achieving the full benefits of an affiliation — operational efficiencies, cost savings and enhanced clinical value.

The most effective BPOEs are developed from the ground up. Departmental leaders identify detailed action items for aligning administrative, support, infrastructure and clinical functions. The key is to capitalize on the operational strengths of each organization and each department. A BPOE should:

  • identify and quantify specific affiliation-related cost-saving opportunities within each department;
  • identify barriers to achieving the efficiencies;
  • identify the resource and time requirements necessary to implement the action plans;
  • lay out a game plan for aligning specialty programs throughout the system;
  • ensure accountability by specifying the individuals responsible for implementing the plan.

Ultimately, the goal is to develop a clear list of achievable and sustainable performance improvement initiatives that will enhance efficiency and reduce the underlying cost structure of the system.

When Should You Develop a BPOE?

Many partnering organizations craft a BPOE before any affiliation agreement is signed. This lets system leaders proactively identify savings opportunities after the transaction. A pre-transaction BPOE also might be required for regulatory approval by the state department of health, state attorney general, Federal Trade Commission or the Department of Justice.

An inherent limitation of a pre-transaction BPOE is that the prospective partners are unable to share competitively sensitive information before closing. This limits the specificity and detail of cost-saving opportunities and action plans. But provisional BPOEs developed before the transaction are directionally accurate; they can also ensure that the prospective partners are strategically and culturally compatible.

A BPOE can be developed or refined with specificity and clarity after the transaction, even if the merger or affiliation took place some time ago. Many systems that have merged or affiliated in recent years have yet to realize the full benefits of operational integration. If this is your situation, commission a multidisciplinary team to revisit previous efforts. The team should develop a BPOE that identifies redundant costs as well as new strategies for better integrating, standardizing and consolidating functions.

Four Reasons to Invest in a BPOE

Every affiliation, merger or acquisition is unique. Every health system's story — and how it came to exist in its current form, with its current culture — is unique. In the background are variations within the consumer and payer markets, differences in strategic and operational strengths and weaknesses, and cultural nuances. These factors drive the need for a customized integration plan for every new partnership. A well-designed BPOE offers four important benefits:

1. A clear leadership structure. The most contentious point in transactions often centers on a single question: Who will be in charge? While it is critical to clearly define the executive hierarchy for the system and its business units (e.g., hospital, physician group, post-acute), it is just as important to outline the cascading leadership structure throughout all departments within the system.

Effective BPOEs identify the leadership positions most appropriate for consolidation; they also establish centralized management for all administrative, support and infrastructure functions. This not only creates consistency in decision-making, it facilitates and streamlines integration efforts. Adopting matrix organizational and reporting structures also will foster standardization of system processes, while allowing for moderate variation when needed to account for distinct organizational variables. In addition, developing a centralized leadership structure as part of the BPOE will help middle managers align interdependent integration plans through multidisciplinary teams.

2. Clear ground-level integration plans. For most system integrations, success or failure occurs at the department level. Effective BPOEs use a ground-up planning process to develop detailed departmental action plans that identify specific opportunities, obstacles and accountabilities.

Department-level plans set clear goals that are consistent with the system's integrated vision. Objectives should include standardization of policies and procedures, optimization of staffing resources, alignment of contracted services, standardization of equipment and supplies, and cost reduction through joint purchasing. Departmental plans also should address specific resource requirements, interdependencies with other unit plans, implementation timelines and responsibilities, and specific cost-saving targets.

Departmental action plans provide a detailed implementation path that can be monitored and measured. This establishes a platform for consistent and timely communication about integration activities and milestones. Collectively, the departmental integration plans will lead to a more integrated and streamlined system.

3. Realistic and sustainable cost-saving targets. Carefully developed BPOEs can lead to annualized system cost savings between 4 and 7 percent. However, during the development of the departmental integration plans, all savings opportunities should be validated by both the responsible department and the financial team prior to inclusion in the plan.

BPOE action items should be incorporated into budgets and could require capital resource allocation for implementation, so it is critical to quantify and rigorously validate cost-reduction opportunities in administrative, support, infrastructure and clinical departments. Operational and financial leaders should assess each savings opportunity to ensure it is realistic, achievable and sustainable. This applies to both salary and non-salary savings opportunities.

Non-salary savings opportunities are often easier to implement culturally. Health systems can achieve significant early cost reductions by standardizing equipment and supplies and aligning contractual services. These savings are not only typically achievable in the short term, but are also sustainable.

Salary savings typically are realized over a longer period. While centralizing management leads to early savings, staffing integration and optimization can take time and resources to fully achieve.

4. A strong foundation for a system-oriented culture. Joining two disparate business entities within a single consolidated health system is inherently difficult, and effectively integrating long-standing legacy cultures is a critical hurdle that can cause a partnership to succeed or fail. Leaders must encourage a cultural transition that moves the organizational focus from business unit priorities to collective system goals and overall performance. A robust BPOE process can aid this cultural transition.

BPOE development uses a structured approach that includes a blend of objective quantitative analyses and key stakeholder engagement. Stakeholder meetings provide a thorough understanding of the existing cultures and organizational barriers to integration. This helps to engage key stakeholders in the process while grounding discussions and action plans in organizational realities. Ultimately, the BPOE process challenges the existing provider organizations individually and collectively to think beyond current practices and strive collaboratively to improve performance as a system.

Protection Against Inaction

In a world that is becoming less hospital-centric, hospitals and health systems are trying to refashion themselves as care continuum organizations through strategic mergers and affiliations. But too often, good intentions fall by the wayside as inertia, politics and other obstacles prevent partnering organizations from realizing the opportunities of integration.

A well-designed business plan of operational efficiency guards against inertia by providing specific, achievable integration goals and action plans. Whether your organization is pursuing a new affiliation or is looking to maximize existing health system performance, a BPOE is an essential tool to achieving true system-level operational integration.


B_Klar.jpg

Mr. Klar is a senior manager with GE Healthcare Camden Group with over 12 years of experience in healthcare management. Mr. Klar specializes in strategic and business planning advisory services, including service line planning, master facility planning, and transaction work (e.g., mergers, acquisitions, affiliations, joint ventures). He has extensive experience in the creation of strategic partnerships, the facilitation of inaugural health system strategic plan development, as well as the creation and implementation of business plans of operational efficiency, system-wide integration plans, and clinical programmatic alignment plans. He may be reached at brandon.klar@ge.com.

 

Topics: Value-Based Care, Payment-for-Value, Business Plan of Operational Efficiency, BPOE, Brandon Klar, Value-Based Payments

Facing Bundled Payments

Posted by Matthew Smith on Feb 19, 2016 9:40:29 AM

By Dominic Foscato, Vice President, GE Healthcare Camden Group

Change in reimbursement isn’t waiting for tomorrow. It’s happening right now. Rather than paying for each procedure and office visit, government and private health plans are moving toward a payment model based on the health of an organization’s patient population. During this transition, an organization’s success depends on its ability to manage a variety of payment models.

Health care organizations must successfully administer these payment models — which continue to evolve and grow more complex —while optimizing quality, outcomes and patient satisfaction. In short, they must manage “fusion reimbursement” or risk significant cuts in revenue.

Bundled Payments

Reprinted with permission from the February 2016 issue of Trustee magazine, vol. 69, no. 2. © Copyright 2016 by Health Forum Inc. Permission granted for digital use only

Topics: Bundled Payments, Value-Based Payments, Alternative Payment Models, Dominic Foscato

Top Predicted Healthcare Trends of 2016

Posted by Matthew Smith on Jan 20, 2016 10:48:00 AM

The nation's healthcare system will undergo tremendous changes in 2016. While macro factors are at play, some of the greatest challenges will be finding ways to respond to new payment models, consumer expectations, as well as changing organizational operations, facilities, and culture to respond to population health strategies. Here's a look at the trends and factors that will have the greatest impact during 2016:

Macro Issues: A Changing Industry

  • The World is Shrinking. Consolidation is one of the biggest phenomena occurring in every arena of healthcare. While we can expect the regulatory approvals for the major payer transactions to be resolved during 2016, keep an ear to the ground for additional mergers. As the number of players shrinks, this will impact both payer and provider strategies, particularly in markets where the payer mix is already highly concentrated. In the provider realm, there will be additional eyes focused on these actions as the Federal Trade Commission will continue scrutiny of provider consolidations, including hospital and medical group acquisitions. "It will be essential to demonstrate direct consumer benefit related to efficiency, access and quality, both pre- and post-merger," said Laura Jacobs, president, GE Healthcare Camden Group. Watch for consolidation to take many forms -- not just asset mergers but many other types of affiliations and integrated relationships.
  • Innovation Will Rock the Boat. From technology, to new models of care, to new approaches to patient experiences, innovation will cause ongoing marketplace disruption. Private equity dollars will continue to flow into mobile technology, while new primary care delivery models and telehealth will offer different ways to engage consumers. In addition, retail giants like CVS and Walgreens/Rite-Aid will push further into care delivery, pressuring traditional providers to enhance access, change delivery models, and/ or forge partnerships to address this issue. At the same time, healthcare organizations will be required to enhance efforts to improve the patient experience far beyond measuring patient satisfaction -- the experience must be exceptional at every encounter -- from electronic to face-to-face visits.
  • Expansion and Redefinition of Health Systems. Health systems will continue to expand their physician enterprise, although many will be challenged by the financial strain of operating large employed models. Compensation redesign to move away from strictly productivity-driven models will be a priority. Expansion and merging of clinically integrated networks will continue, as a vehicle to align incentives in population health and value-based payment models, as well as minimize the need for "owning and controlling" the continuum. Expect ongoing development or expansion of provider-owned health plans as either a counterweight to the highly concentrated payer market or a means of taking global risk with payers or employers. Meanwhile, payers will extend their reach into the care delivery space, acquiring physician practices and clinical networks.

Follow the Money

  • Transparency and the Pocketbook. Pressures related to price and cost -- along with the adjacent need for transparency -- will drive more transformation. Consumer scrutiny will play an increasing role in this dynamic as high deductible plans force them to pay closer attention to price. As a result, lower-cost alternatives will have a competitive advantage. Because payer rate increases will be in the low single digits (if at all), any upside will require participation in some value-based payment, such as shared savings or pay-for-performance. In addition, thanks to the new budget bill, new provider-based clinics will not be reimbursed any more than physician practices. These pressures will continue to force more efficiencies across the continuum related to patient throughput and require operating cost reductions, moving from cost-per-unit to cost-per-episode basis.
  • The Variety Show: Value-Based Payments. Value-based initiatives may radically change referral patterns and the need for effective population health management. For an example, consider the 2015 introduction of the Comprehensive Care for Joint Replacement (CJR) model for Medicare -- with a roll-out in 2016. There is no way to predict how quickly new similar initiatives could strike your market. In addition, as employers introduce narrow networks to better control costs, some markets will experience acceleration of employer direct contracting. Further, the "foot in two canoes" analogy will have to change to recognize the proliferation of payment models beyond a strict definition of fee-for-service vs. fee-for-value. The cacophony of models ranging from strictly fee-for-service to pay-for-performance, care management/patient-centered medical home, bundled payment, shared savings/ACO, full or partial risk/capitation, and beyond will continue to add administrative, strategic, operational, and financial complexity to most organizations. Trying to make sense of this blend of payment structures from both a financial and care model perspective will cause more confusion before the fog clears.
  • Increased Focus on Post-Acute Care. The spotlight will shine on post-acute care, thanks to population health management models and bundled payment. We'll see the emergence of "preferred" networks of providers providing these services, as well as repurposing acute care facilities to meet the needs of post-acute patients. More transactions involving post-acute providers -- home health, skilled nursing, rehabilitation, hospice ­-- will create increased upheaval in this realm of healthcare.

Inside the Walls

  • Patient Volume: The Seesaw Effect. Changing dynamics in the healthcare system will have a give-and-take impact on patient volume. While new payment models will decrease acute hospital utilization, the continued expansion of Medicaid and the insured population through the public exchanges will push additional patients through the doors. Additional factors feeding demand across the spectrum include an aging population and the ongoing rise of obesity and chronic disease. Although urgent care, better care management and redesigned primary care models will eventually deflect patients from the emergency department, the ultimate impact of these initiatives will take a while, requiring these areas of hospital to operate at (or over) capacity.
  • The People Factor. Change cannot occur without effective leadership, leading to an increased demand for clinical leaders who can help drive transformation. Participation in population health management will increase competition, as well as cost, for these capabilities. At the same time, there will be leadership turnover as mergers/consolidations occur and as systems evolve from "holding company" to "operating company" models (and sometimes back again). Finally, be on the lookout for union activity, which may be sparked in some regions due to cost pressures and reductions in force.
  • The Makeover. As administrators "rationalize" clinical service lines, they will strive to reduce variation in quality and cost across health systems. Physician alignment with these moves will be crucial. Simultaneously, consolidations and mergers will spawn a new wave of facility planning to repurpose or enhance the efficiency of existing structures.
  • The Rise of IT and Turf Wars. One area where capital will continue to flow: IT tools and resources. The need for new structures for data governance within health systems will be driven by the proliferation of population health tools and analytical systems. And in a related development, watch for a tug-of-war between CIOs and business unit leaders. Turf battles may ensue on selection of systems and data management.

Topics: Trends, Post-Acute Care, Value-Based Payments

Looking Ahead in 2016: Top 10 Trends in Healthcare

Posted by Matthew Smith on Jan 6, 2016 3:56:21 PM

By Laura P. Jacobs, M.P.H., President, GE Healthcare Camden Group

While some current trends will continue into 2016, keeping pace with local market changes will require foresight and nimble leadership. Watch for these potential change “accelerators” for 2016.

Consolidation The major payer consolidations likely will get ironed out during 2016. The degree to which your payer market is already highly concentrated will affect your payer strategy, but watch for additional consolidation and its potential effect. Furthermore, the Federal Trade Commission will continue to scrutinize provider consolidations, including hospital as well as medical group acquisitions. The degree to which any anticipated affiliations or acquisitions truly achieve consumer benefit in terms of efficiency, access and quality must be clearly demonstrated both pre- and post-merger.

Government, commercial payer and employer move to value-based payment  As illustrated by the Centers for Medicare & Medicaid Services' introduction of the Comprehensive Care for Joint Replacement model for Medicare, there is no predicting how quickly certain initiatives could strike your market. Also, employer direct contracting will pick up in some markets as employers introduce narrow networks to control costs better. These initiatives can radically change referral patterns and the need for effective population health management.

To continue reading this article in its entirety, please click the button below to immediately access the article on the Hospitals & Health Networks website.

2016 Healthcare Trends, GE Healthcare Camden Group

Topics: Trends, Laura Jacobs, Care Model Redesign, Value-Based Payments

Patient Access Innovations: Integrating Patients Within the System of Care

Posted by Matthew Smith on Dec 1, 2015 3:21:44 PM

Provider coordination is of paramount importance for healthcare organizations preparing for the industry’s shift in focus from volume to value. The most ambitious coordination model that has been developed to date is the clinically integrated network ("CIN")—a contractual collaboration among hospitals, physicians, and other providers to manage patients across the entire continuum of care. A CIN uses population health management tools, including care management techniques, to build value through improving patient outcomes and controlling costs. This innovative model offers providers access to value-based payment contracts and an opportunity to improve quality and reduce costs.

Despite the compelling benefits of clinical integration, this approach also poses risks. Value-based payment contracts hold CIN participants accountable for both clinical and financial outcomes, although the ability to influence these outcomes depends largely on patient choice and patient compliance. Whenever a patient leaves the CIN, even if the patient returns to the network for certain services, network providers lose the opportunity to fully manage the patient’s care and utilization, ultimately undercutting their ability to coordinate the patient’s care and accrue the benefits of improved clinical outcomes and reduced costs.

This risk makes it critically important for CINs to keep patients within their organized systems of care. CINs need to make sure patients can access the network easily and are motivated to stay connected, requiring a strategic focus on patient access and engagement.

Based on the experiences of leading CINs, strategies aimed at improving patient access tend to be most effective when they are focused on three primary objectives: expanding entry points to the network, making access more convenient and inexpensive, and keeping patients engaged in the care they receive from network providers. The following five strategies, in particular, have been proven effective for ensuring in-network access and strengthening patient engagement.

To read the rest of this article in its entirety, please click the button below to immediately access the article on the hfm magazine site:

 Patient Access, Clinically Integrated Networks

Topics: Clinical Integration, Clinically Integrated Networks, Patient Access, Patient Engagement, Daniel J. Marino, Value-Based Payments

Subscribe to Email Updates

Value Model, Health Analytics

Posts by Topic

Follow Me