Recently, CMS set a clear path to creating new risk sharing programs for providers through alternative payment models such as Bundled Payments for Care Improvement (BPCI), which my colleague Tracy outlined well in this terrific post. The broad based BPCI program gave way to more specialty specific programs such as the Oncology Care Management Model, Nephrology’s ESRD Care Model, and Orthopedics’ Comprehensive Care for Joint Replacement model.
Collectively these programs signal a new era where previously disparate episodes of care are financially bound together. The new twist is that the payments, and hence risk, cover multiple providers and multiple sites of care. Now providers in different businesses are wrapped together in common financial risk, where before they operated independently. This new dependence asks more of each patient encounter and as a result, communication and coordination needs are growing exponentially.
These new alternative payment programs have a common general structure. First, each requires a risk period that includes all patient costs over a period ranging from 30 to 90 days. Second, each requires certain quality metrics be met. Third, each requires certain financial outcomes usually obligating an organization to operate at lower than its historical cost over the risk period. The organization can earn bonuses if the cost performance is below historical cost, or they must repay CMS for any costs that run above historical cost.
The first two elements trigger a need to work collaboratively with other caregivers given that most patients receive care from a variety of providers over such time periods. The last element, financial outcomes, acts to incentivize broad engagement since it can reward physicians with bonuses. Organizations can theoretically make up to a 50% bonus on their Medicare reimbursements occurring within the program. Taken together, these elements: risk, quality, and financial performance, require providers to be particularly attentive to the decision-making around patients in these programs. Each decision made at the point of care by an individual provider affects risk, quality, and finances not only for themselves, but also for every provider involved in the program.
On the Ground
Given this new importance of decision making at the point of care, there is a lot of new information to consider. Each risk period starts in the hospital and follows the patient into their post acute outpatient settings, which are typically owned by a different entity than the hospital. Thus, doctors at the point of care need to evaluate information such as:
• What is the site of care best suited for the patient’s condition: a skilled nursing facility, Home Health, inpatient rehab, or acute long term care?
• What site of care promises the best outcomes?
• Which particular provider will do the best job with that particular patient’s diagnosis and needs?
• How do we discuss this with the family and their particular dynamics and medical literacy?
• What quality measures are unmet for that patient?
How to get all of this information to the provider at the point of care - where decisions about the best, most effective care path for the patient must be made - is a growing problem. Further complicating matters are:
• The availability and continuity of the hospital case managers who have a primary responsibility to get patients discharged from the hospital in a timely manner;
• The many physicians who may be on the case with their demanding caseload;
• The frequent uncertainty of who would follow the patient post discharge and the families’ desire to have the patient’s needs fit into their busy lives.
All in all, this is a lot of new information to address at the point of care, and some of it quite complex with many different and diverse audiences. These data points highlight the very real question of who will be consistently available to deliver the information needed.
So therein lies the challenges for success in any of these Alternative Payment Models. There are new outcomes to consider spanning up to 90 days of care across all care settings, many beyond your walls, with a quality scorecard to meet. All of this impacts financial risk if the goals aren’t met. It seems inevitable that technology must rise to the task of delivering this data at the point of care, if alternative payment programs are to ever succeed. However, the challenge for those who seek to enable with technology is how well they can understand this thicket of needs and help you build the right care network, around each patient, extending to all the places you need it to go, and to all the people you need involved. I came to pMD to tackle such complex issues. Here, we love your difficult challenges.