Stuck in Neutral: Bundled Payments and Post-Acute Providers
After CMS nixed the mandatory expansion provisions for Bundled Payments and reduced the metro areas participating in CJR (joint replacement), the prospects for post-acute provider involvement in non-fee-for-service initiatives (payments and incentives based on disease states and care episodes) went in to limbo. With a fair amount of excitement and trepidation building on the part of the post-acute world about different payment methodologies, new network arrangements, new partnerships, incentive possibilities, etc., CMS put the brakes on the “revolution”; a screeching halt.
While Bundled Payments aren’t dead by any means, the direct relationships for post-acute providers are in “neutral”. The Bundled Payments for Care Improvement Advanced (BPCI Advanced) initiative announced in January included no avenue for SNFs, HHAs (home health) to apply and participate. Nationally, other voluntary bundle programs continue including the remnants of CJR, and Models 2, 3 and 4 in Phase II. According to CMS, as of April of this year, 1100 participants were involved in Phase 2 initiatives. The Phase 2 initiatives cover 48 episodes of care ranging from diabetes, through various cardiac issues and disease to UTIs.
BPCI Advanced opportunities (episode initiators) involve hospitals or physician groups. Post-acute will still play a role but the direct connections and incentives aren’t quite tangible or specific, compared to CJR. Time will tell how the roles for post-acute providers evolve in/with BPCI Advanced. Oddly enough, the economic realities of care utilization and negative outcome risk suggest that post-acute should play a direct, large role. As hospital stays shorten, outpatient and non-acute hospital surgical procedures increase, the directed discharge to post-acute has taken on greater meaning in the care journey. HHAs in particular, are playing an expanded role in reducing costs via enhancements to their ability to care for more post-surgical cases direct from the hospital/surgical location. Simultaneous however, readmission risk exposure increases. What is certain is that system-wide, the window of 30 to 90 days post hospital or acute episode is where significant efficiency, quality and cost savings improvement lies.
While the direct opportunities initially forecast under BPCI for the post-acute industry have evaporated (for now), strategic benefits and opportunities remain. Providers should not stray from a path and process that focuses on enhancing care coordination, improving quality and managing resource utilization. Consider the following:
- For SNFs, PDPM (new proposed Medicare reimbursement model) incorporates payment changes and reductions based on length of stay (longer stays without condition change, decrease payment after a set time period). A premium is being placed on getting post-acute residents efficiently, through their inpatient stay.
- For HHAs, payment reform continues to focus on shorter episodes in the future. Like PDPM for SNFs, the focus is on efficiency and moving the patient through certain recuperative and rehabilitative phases, expeditiously.
- Medicare Advantage plans are increasing market share nationwide. In some markets, 60% of the post-acute days and episodes are covered by Medicare Advantage plans – not fee-for-service. These plans concentrate on utilization management, ratcheting stay/episode length and payment amounts, down. Providers that again, are efficient and coordinate care effectively will benefit by focused referrals and improved volumes.
- Quality matters more than ever before – for all providers. Star ratings are increasingly important in terms of attracting and retaining referral patterns Networks and Medicare Advantage plans are focused on sourcing the highest rated providers. Upstream referral sources, concerned about readmission risks are targeting their discharges to the higher rated providers. Consumers are also becoming more market savvy, seeking information on quality and performance. And of course, government programs such as Value-Based Purchasing place providers with poor performance on key measures (readmissions for SNFs) in the reimbursement reduction pool.
- Indirectly, Bundled Payment initiatives move forward and the Advanced option will require physicians and hospitals that participate, to source the best referral partners or lose incentive dollars and inherit unwarranted readmission risk. SNFs and HHAs that excel at care coordination, length of stay management, have disease pathways in-place, can manage treatment, diagnostic and pharmacology expenses and produce exceptional outcomes and patient satisfaction are the preferred partners.
Interoperability and Post-Acute Implications
I’m not sure how many of my readers are following the subject and CMS stance/policy on interoperability among providers but the concepts and resultant debate are rather interesting. I am trying to encourage as many clients and readers to tune-in on this subject as the implications are sweeping – positively and negatively.
Interoperability in this context means the ability of computer systems or software to exchange and/or make use of information for functional purposes. In health care, the genesis of the interoperability concept began with HIPAA in the nineties. HIPAA spawned the HITECH Act in 2009 which ultimately created Meaningful Use. For anyone unfamiliar with Meaning Use and its incentive provisions, think no further than Value-Based Purchasing (VBP) and quality reporting. The IMPACT Act is an analogous outgrowth of blended concepts between Meaningful Use, Value-Based Purchasing and Interoperability. Conceptually, the goal is to create data measures that have “meaning” in terms of clinical conditions, outcomes, patient care and economics. Ideally, data that matters and can be shared will improve outcomes, improve standardization of care and treatment processes and reduce cost through reduced waste and duplication. Sounds simple and logical enough.
In April of this year, with the roll-out of various provider segment Inpatient PPS proposed rules for FY 2019, CMS included proposals to strengthen and expedite, interoperability. The concept is contained within the SNF and Hospital proposed rules. The twist however, is that CMS is changing its tone from “voluntary” to “mandatory” regarding expediting or advancing, interoperability. Up until this point, Meaningful Use projects that advanced interoperability goals were incentive driven; no punishment. Among the options CMS is willing to pursue to advance interoperability are new Conditions of Participation and Conditions for Coverage that may include reimbursement implications (negative) and fines for non-compliance and non-advancement. In the SNF 2019 Proposed Rule, providers are mandated to use the 2015 Edition of Certified Health Record/Information Technology in order to qualify for incentive payments under VBP and avoid reimbursement reduction(s). For those interested, the 2015 Certified EHR Technology requirement summary is available here: final2015certedfactsheet.022114
The possible implications for providers are numerous – positive and negative. The greatest positive implication is a (hopeful) rapid escalation of software systems that can share functional data directly without having to build and maintain separate interfaces (third-party). Likewise, the proposed regulations will facilitate faster development of Health Information Exchanges (HIEs). Many states have operating HIEs but provider participation and investment has been limited. A quick interoperability interchange is via an HIE versus separate, unique data and software platform integration. As SNFs and HHAs have MDS and OASIS assessment requirements on admission, fluid patient history, diagnoses/coding exchange and treatment history will facilitate faster and more accurate, MDS/OASIS completion – a real winner. Dozens of other “tasky” issues can be addressed as well such as portions of drug reconciliation requirements by diagnosis on admission, review of lab and other diagnostic results, order interchanges and interfaces, etc.
The most negative implication for providers is COST. In reality, the post-acute side of health care isn’t really data savvy and hasn’t really kept pace with software and technology developments. Many providers are small. Many providers are rural. Many providers maintain primarily paper records and use technology only minimally. Full EHR for them is impractical and with present reimbursement levels, unlikely any time soon. The second most negative implication for providers is the fragmentation that exists among the system developers and software companies in the health care industry. The “deemed” proprietary nature of systems and their software codes has limited collaboration and cooperation necessary to advance interoperability. HIEs were supposed to remedy this problem but alas, not yet and not at the magnitude-level CMS is foretelling within its Proposed Rules.
Interoperability is needed and amazing, conceptually. The return is significant in terms of improvements in outcomes and reductions in waste and cost. Unfortunately, the provider community remains too fragmented and inversely incentivized today to jump ahead faster (money not tied to integration and initiatives among providers). Software systems don’t work between providers in fashions that support the interoperability goals. More troubling: the economics are daunting for providers that are not seeing any additional dollars in their reimbursements, capable of supporting the capital and infrastructure needs part and parcel to additional (and faster), interoperability.
SNFs and PBJ Article
Attached is a link a to a good PBJ (payroll based journal) article. It covers the basic concepts of what is going on today with regard to staffing level reporting and the Five Star system. Recall, staffing as a domain, is one of the stars in this system. The article is posted here (re-published) with permission of the original publication. Enjoy!
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