HCP-LAN Clinical Episode Payments

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ALLRIGHTSRESERVED
1 2016TheMITRECorporation.ALLRIGHTSRESERVED.
CONTENTS
AbouttheCMSAlliancetoModernizeHealthcare.......................................................................................2
ExecutiveSummary.......................................................................................................................................3
Chapter1:Overview.....................................................................................................................................6
Chapter2:SummaryofEpisodeRecommendations..................................................................................12
Chapter3:ElectiveJointReplacement.......................................................................................................16
Recommendations:ElectiveJointReplacement.........................................................................................17
Chapter4:MaternityCare..........................................................................................................................41
Recommendations:MaternityCare............................................................................................................45
Chapter5:CoronaryArteryDisease...........................................................................................................66
Recommendations:CoronaryArteryDisease.............................................................................................69
Chapter6:OperationalConsiderations......................................................................................................94
1.
RoleandPerspectivesofStakeholders...........................................................................................94
2.
DataInfrastructureIssues...............................................................................................................96
3.
RegulatoryEnvironment.................................................................................................................98
4.
InteractionbetweenCEPandPopulationBasedPayment...........................................................100
Chapter7:Conclusion...............................................................................................................................103
AppendixA:Roster...................................................................................................................................105
AppendixB:Acknowledgements..............................................................................................................107
AppendixC: ElectiveJointReplacementBundledPaymentModels ........................................................108
AppendixD:
MaternityCareBundledPaymentModels
...........................................................................115
AppendixE:CoronaryArteryDiseaseBundledPaymentModels
............................................................
123
AppendixF:ElectiveJointReplacementImplementationResources.......................................................
126
AppendixG:
MaternityCareImplementationResources
.........................................................................130
AppendixH:CoronaryArteryDiseaseImplementationResources..........................................................134
AppendixI:LANRelatedContent.............................................................................................................138
AppendixJ:PrinciplesforPatientandFamilyCenteredPayment.......................................................... 140
AppendixK:Resources..............................................................................................................................142
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AbouttheCMSAlliancetoModernizeHealthcare
TheCentersforMedicare&MedicaidServices(CMS)sponsorstheCMSAlliancetoModernize
Healthcare(CAMH),thefirstfederallyfundedresearchanddevelopmentcenter(FFRDC)dedicatedto
strengtheningournationshealthcaresystem.TheCAMHFFRDCenablesCMS,theDepartmentofHealth
andHumanServices(HHS),andothergovernmententitiestoaccessunbiasedresearch,advice,
guidance,andanalysistosolvecomplexbusiness,policy,technology,andoperationalchallengesin
healthmissionareas.TheFFRDCobjectivelyanalyzeslongtermhealthsystemproblems,addresses
complextechnicalquestions,andgeneratescreativeandcosteffectivesolutionsinstrategicareassuch
asqualityofcare,newpaymentmodels,andbusinesstransformation.
FormallyestablishedunderFederalAcquisitionRegulation(FAR)Part35.017,FFRDCsmeetspecial,long
termresearchanddevelopmentneedsintegraltothemissionofthesponsoringagencyworkthat
existinginhouseorcommercialcontractorresourcescannotfulfillaseffectively.FFRDCsoperateinthe
publicinterest,freefromconflictsofinterest,andaremanagedand/oradministeredbynotforprofit
organizations,universities,orindustrialfirmsasseparateoperatingunits.TheCAMHFFRDCappliesa
combinationoflargescaleenterprisesystemsengineeringandspecializedhealthsubjectmatter
expertisetoachievethestrategicobjectivesofCMS,HHS,andothergovernmentorganizationscharged
withhealthrelatedmissions.Asatrusted,notforprofitadviser,theCAMHFFRDChasaccess,beyond
whatisallowedinnormalcontractualrelationships,togovernmentandsupplierdata,includingsensitive
andproprietarydata,andtoemployeesandgovernmentfacilitiesandequipmentthatsupporthealth
missions.
CMSconductedacompetitiveacquisitionin2012andawardedtheCAMHFFRDCcontracttoTheMITRE
Corporation(MITRE).MITREoperatestheCAMHFFRDCinpartnershipwithCMSandHHS,andmaintains
acollaborativeallianceofpartnersfromnonprofits,academia,andindustry.Thisallianceprovides
specializedexpertise,healthcapabilities,andinnovativesolutionstotransformdeliveryofthenations
healthcareservices.Governmentorganizationsandotherentitieshavereadyaccesstothisnetworkof
partners,includingRANDHealth,theBrookingsInstitution,andotherleadinghealthcareorganizations.
Thisincludesselectqualifiedsmallanddisadvantagedbusiness.TheFFRDCisopentoallCMSandHHS
OperatingDivisionsandStaffDivisions.Inaddition,governmententitiesoutsideofCMSandHHScanuse
theFFRDCwithpermissionofCMS,CAMHsprimarysponsor.
ExecutiveSummary
TheHealthCarePaymentLearning&ActionNetwork
(LAN)wascreatedtodrivealignmentinpayment
approachesacrossandwithinthepublicandprivate
sectorsoftheU.S.healthcaresystem.Toadvancethis
goal,theClinicalEpisodePayment(CEP)WorkGroup
(theWorkGroup)wasconvenedbytheLANGuiding
Committeeandchargedwithdeveloping
recommendationsforthepurposeofaccelerating
adoptionofalignedclinicalepisodepaymentmodelsin
theareasofelectivejointreplacement,maternitycare,
andcoronaryarterydisease.Composedofdiversehealth
carestakeholders,theWorkGroupdeliberated,
incorporatedinputfromLANparticipants,andreached
consensusonmanycriticalissuesrelatedtodesigning
personcenteredclinicalepisodepayment,whichisthe
subjectofthisWhitePaper.
Clinicalepisodepaymentmodelsaredifferentfrom
traditionalfeeforservice(FFS)healthcarepayment
models,inwhichprovidersarepaidseparatelyforeach
servicetheydeliver.Instead,clinicalepisodepayment
modelstakeintoconsiderationthequality,costs,and
outcomesforapatientcenteredcourseofcareovera
setperiodoftimeandacrossmultiplesettings.This
courseofcareisknownastheclinicalepisode.Research
suggeststhatwhenpaymentsforhealthcarearebased
onthecaredeliveredinaclinicalepisode,theresultis
increasedcoordinationofcare,enhancedqualityofcare,
andlessfragmentationinthemedicalsystem.Thisleads
tobetterexperiencesandhealthforpatientsandlower
costsforpayersandproviders.
Sincethefirstepisodepaymentswereintroducedmore
than30yearsago,publicandprivatepurchasers(anda
rangeofdeliverysystems)haveexploredavarietyof
episodepaymentmodelswithvaryingdegreesof
success.Thisisbecause,asresearchhasshown,while
episodepaymentsoffergreatpotentialasanalternative
toFFScare,designingandimplementingsuchmodels
comeswithfinancial,technological,cultural,logistical,
andinformationalobstacles.Thesechallenges,along
withthesheerdiversityofdesignsandapproaches
currentlyinuse,havemadeitdifficulttopromote
alignmentandaccelerationofpaymentmodelsacross
theU.S.healthcaresystem.
HealthCarePayment
Learning&ActionNetwork
Toachievethegoalofbettercare,
smarterspending,andhealthier
people,theU.S.healthcaresystem
mustsubstantiallyreformits
paymentstructuretoincentivize
quality,positivehealthoutcomes,
andvalueovervolume.Such
alignmentrequiresafundamental
changeinhowhealthcareis
organizedanddeliveredandrequires
theparticipationoftheentirehealth
careecosystem.TheHealthCare
PaymentLearning&ActionNetwork
(LAN)wasestablishedasa
collaborativenetworkofpublicand
privatestakeholders,includinghealth
plans,providers,patients,employers,
consumers,states,federalagencies,
andotherpartnerswithinthehealth
careecosystem.Bymakinga
commitmenttochangingpayment
models,establishingacommon
framework,aligningapproachesto
paymentinnovation,sharing
informationaboutsuccessfulmodels,
andencouraginguseofbest
practices,theLANcanhelpreduce
barriersandacceleratetheadoption
ofalternativepaymentmodels
(APMs).
U.S.HealthCarePaymentsinAPMs
Thus,theCEPWorkGroupschargewasto:
Provideadirectionalroadmapforproviders,healthplans,patientsandconsumers,purchasers,and
states,basedonexistingeffortsandinnovativethinkingintherealmofclinicalepisodepayment;
PromotealignmentinbothCEPdesignandoperationalapproach;
Strikeabalancebetweenalignment/consistencyandflexibility/innovation;
Findthebalancebetweenshorttermfeasibilityandlongtermaspiration;and
RecognizetheeffectsofanevolvinghealthcaresystemonthedesignandimplementationofCEP.
TheWorkGroupselectedthreeclinicalfocusareasonwhichtobuildepisodepaymentmodels:elective
jointreplacement(EJR),maternitycare,andcoronaryarterydisease(CAD).Foreachepisodemodel,the
LANreleasedadraftWhitePaperthatlaidoutasetof10designelementrecommendations,aswellas
operationalconsiderations.EachdraftWhitePaperwasmadeavailabletothepublicfora30day
commentperiod,andthosecommentsresultedinsignificantrevisionsacrossseveraldesignelement
recommendations.
Anumberofcrosscuttingthemesemergeacrossallthreeepisodes:
Consumer,patient,andfamilyengagementiscriticaltodrivingvaluebasedcare:Atthepatientlevel,
thismeansengagingindividualpatientsandfamiliesandsupportingtheminbeingpartnersintheircare.
Atthesystemlevel,thisinvolvesengagingconsumers,patients,families,andtheiradvocatesin
meaningfulparticipationinthedesign,implementation,governance,evaluation,andquality
improvementofepisodepaymentmodels.Engagementcanbereflectedbyprovidersacknowledging
andincorporatingthetypesofcarethatpatientsvalue;orbypayers,purchasersandprovidersensuring
thatinformationaboutpaymentandreimbursementisavailableinawaythatislinguisticallyand
culturallyappropriateandtailoredtothehealthliteracylevelofpatientsandfamilies.Otherspecific
examplesofhowtofacilitatethisengagementarefoundthroughoutthepaper.
Inclinicalepisodeswithnumerouscareteammembers,thereareanumberofvariablestoconsiderin
assigningaccountability:Acommonfeatureacrossthethreeclinicalepisodesdescribedinthispaper,as
wellasclinicalepisodesingeneral,isthattheyarecomposedofcaredeliveredinmultiplesettingsbya
careteamthatincludesnumerouscliniciansandotherproviders.WhiletheWorkGroupinitially
intendedtorecommendspecifictypesofproviders(e.g.thepatientscardiologistorprimarycare
providerinthecoronaryarterydiseaseepisode),thefinalrecommendationdescribesthemany
variablesthatplayintoacliniciansabilitytotakeresponsibilityforthepatient,bothfromafiscaland
fromaqualityoutcomesstandpoint.Thesevariablesmayapplyregardlessoftheclinicalfocusforany
givenepisodepaymentmodel.
Certaindesigndecisionshingeonwhetherimplementationismandatoryorvoluntary:AstheWork
Groupstudiedandanalyzedmanyepisodepaymentinitiatives,akeyelementthatseemedtodrive
variousdesigndecisionswaswhethertheinitiativewasvoluntaryforprovidersorwhetheritwasa
programmandatedbythestateorotherentity.Forexample,ifastatemandatesepisodepaymentinits
Medicaidprogram,itmayhavemoreleewaytorequirethatproviderstakeonbothupsiderewardas
wellasdownsiderisk.Inavoluntaryinitiative,thepayer(orotherimplementer)maydesignthe
programaroundupsiderewardonly,whileencouragingproviderstoachieveastateofreadiness
necessarytotakeondownsiderisk.
Usinghistoricaldatatodeterminetheepisodepricecreateschallengesforpaymentandcare
transformation:Settingtheepisodepriceisacriticalaspectofepisodepaymentdesign.Yet,itcreatesa
significantchallenge.Historicaldataiscrucialtogivingpayersandprovidersanunderstandingofthe
resourcesneededtodeliverhighqualitycareandoptimaloutcomes.However,thatsamehistoricaldata
maylikelyreflectcarethatwasunnecessaryorinappropriate,andmaynotreflectthepotentialforlow
cost,highvalueservicesthathavetraditionallynotbeenusedbecausetheprovidersdonotgetpaidfor
them.Theseincludecarecoordinationservices,lifestylechangesupport(inthecaseofcoronaryartery
disease),orprenatalparentingeducationsupport(inthecaseofmaternitycare).
Arobustdatainfrastructureiscriticaltoanepisodepaymentmodelssuccess:TheWorkGroupheard
frommanycommentersabouttheimportanceofproviders,payers,patients,andpurchasershaving
accesstodatainawaythatsupportsthekindofcarecoordinationandcaredeliverythatiscentralto
optimizingoutcomesforpatientsviaanepisodepaymentmodel.
TheWhitePaperprovidesrecommendationsfordesigningclinicalepisodepaymentintheabove
mentionedclinicalareasofelectivejointreplacement,maternitycare,andcoronaryarterydisease,with
thegoalofcreatingalignedmodelsthatleadtoimprovedoutcomesforpatients.
Asummarydescriptionofthedesignrecommendationsforeachepisodecanbefoundin Chapter2,
EpisodePaymentDesignElements.Chapters3,4,and5,respectively,provideasetofrecommendations
anddetaileddiscussionsaboutclinicalepisodesforelectivejointreplacement, maternity,andcoronary
arterydisease.Chapter6,OperationalConsiderations,discussesissuestoconsiderin movingfrom
episodepaymentdesigntooperationalizationandimplementation.TheWhitePaperconcludeswith
someimmediatenextstepsthatstakeholderscantaketoadvancetheWorkGroupsrecommended
approachtodesigningclinicalepisodepaymentmodels.
Chapter1:Overview
TheLANestablisheditsGuidingCommittee(GC)inMay2015asthecollaborativebodychargedwith
advancingalignmentofpaymentapproachesacrossandwithintheprivateandpublicsectors.This
alignmentaimstoacceleratetheadoptionanddisseminationofmeaningfulfinancialincentivesto
rewardprovidersandsystemsofcarethatimplementpersoncenteredcare andpatientresponsive
deliverysystems.CAMH,thefederallyfundedresearchanddevelopmentcenteroperatedbythe MITRE
Corporation,wasaskedtoconvenethisnationalinitiative.
InkeepingwiththegoalsofHHS,theLANaimstohave30%ofU.S.healthcarepaymentsinalternative
paymentmodelsby2016and50%by2018.Onepromisingareaforpaymentinnovationandalignment
isinpaymentforepisodesofcaretoimprovepatientoutcomes,enhancehealthsystemperformance,
andcontrolcosts.Aclinicalepisodepaymentisabundledpaymentforasetofservicesthatoccurover
timeandacrosssettings.Thispaymentmodelcanbeappliedinvariousways:
Atthesettinglevel,wherebytheepisodeisfocusedonahospitalstay;
Attheprocedurelevel,inwhichtheepisodeencompassesadefinedsurgicalprocedure;or
Attheconditionlevel,wherebytheepisodeisdefinedaroundacondition.Conditionsforwhich
episodepaymentcanbeusedrangefromasthmatodiabetestocancer.
Bundlingpaymentsforepisodesofcareshowspromiseforreducingcostsandimprovingthequalityof
care.Currently,thereismuchinterestinepisodebasedpaymentmodels.Bothpublicandprivate
purchasersareexploringhowbesttopromoteaccelerationandalignmentofthesemodelsbecause
episodepaymentsofferaparticularlypromisingapproachtoefficientlycreateandsustaindelivery
systemsthatadvancevalue,quality,costeffectiveness,andpatientengagement.
Therecommendationsinthispaperarepresentedwithrecognitionoftheevolvinghealthcaresystem,
andthemanyforcesthatareseekingtoacceleratethemovementfromFFStopayingforvalue.These
includethefederalinitiativesestablishedbytheAffordableCareAct,includingtheCMSInnovation
CenteranditsmodelsliketheBundledPaymentforCareInitiative(BPCI)andComprehensivePrimary
CarePlus(CPC+).ThisalsoincludesmorerecentlegislationaimedatacceleratingtheadoptionofAPMs
liketheMedicareAccessandCHIPReauthorizationAct(MACRA).
Whereacceleratedadoptionofalignedmodelsdoesoccur,itmustdosoinawaythatsupportsperson
centeredcare.Thispaperprovidessubstantiveinformationonhowepisodepaymentmodelscanbe
designedtodojustthat.Meaningfullyengagingconsumers,patients,families,andtheiradvocates
requiresasetoftoolsandinformationthatarecrucialtonotjustepisodepayment,buttoalternative
paymentmodelsoverall(Figure1).Consumers,patients,families,andtheiradvocatesshouldbe
collaborativelyengagedinallaspectsofdesign,implementationandevaluationofpaymentandcare
models,andtheyshouldbeengagedaspartnersintheircare.Personcenteredepisodepaymentmodels
haveastronginvestmentinengagingpatientsinmultipleways,includingsharedcareplanning,shared
decisionmaking,comparativequalityinformation,carecoordination,chronicdiseasemanagement
tools,transparencyofpaymentinformation,andcaretransitionsupport.Tobeeffective,
communicationsandresourcesmustbetailoredtothehealthliteracylevelofpatientsandfamilies,and
belinguisticallyandculturallyappropriate.
Figure1:ToolsforFosteringPatientandFamilyEngagement
PurposeoftheWhitePaper
InNovember2015,theGCconvenedtheCEPWorkGroupandchargedthegroupmemberswith
creatingasetofrecommendationsthatcanfacilitatetheadoptionofclinicalepisodebasedpayment
models(CEPWorkGroupmembersparticipatedinthiseffortasindividualsandnotonbehalfoftheir
respectiveorganizations).TheGCnotedaspecificinterestinmodelsthatfallwithinCategory3APMs
builtonanFFSarchitectureandCategory4populationbasedpaymentof theLANsAlternative
PaymentModelFramework,whichcanbefoundhere.
ClinicalepisodepaymentmodelsaredifferentfromtraditionalFFShealthcarepaymentmodels,in
whichprovidersarepaidseparatelyforeachservicetheydeliver.Instead,clinicalepisodepayment
modelstakeintoconsiderationthequality,costs,andoutcomesofapatientcenteredcourseofcare
overasetperiodoftimeandacrossmultiplesettings.Thiscourseofcareisknownastheclinical
episode.Researchsuggeststhatwhenpaymentsforhealthcarearebasedonthecaredeliveredina
clinicalepisode,theresultisincreasedcoordinationofcare,enhancedqualityofcare,andless
fragmentationinthemedicalsystem.Thisleadstobothbetterexperiencesandhealthforpatientsand
lowercostsforpayersandproviders.
Sincethefirstepisodepaymentswereintroducedmorethan30yearsago,publicandprivatepurchasers
(andarangeofdeliverysystems)haveexploredavarietyofepisodepaymentmodelswithvarying
degreesofsuccess.Thisisbecause,asresearchhasshown,whileepisodepaymentsoffergreatpotential
asanalternativetoFFScare,designingandimplementingsuchmodelscomeswithfinancial,
technological,cultural,logistical,andinformationalobstacles.Thesechallenges,alongwiththesheer
diversityofdesignsandapproachescurrentlyinuse,havemadeitdifficulttopromotealignmentand
accelerationofpaymentmodelsacrosstheU.S.healthcaresystem.
Thus,thepurposeofthispaperistoprovideanepisodepaymentdesignframework,aswellas
recommendationspertainingtoeachofthetenelementsinsaidframework,thatwillsupportadoption
ofalignedepisodepaymentmodelsintheareasofelectivejointreplacement,maternitycare,and
coronaryarterydisease.TheWorkGroupdevelopedtheserecommendationswithrecognitionofthe
evolvinghealthcaresystem,andthemanyforcescurrentlyseekingtoacceleratethemovementfrom
FFStovaluebasedpayment.
PriorityAreas
Withthiscontextinmind,theCEPWorkGroupsvieweditschargeasthefollowing:
Provideadirectionalroadmapforproviders,healthplans,patientsandconsumers,purchasers,and
states,basedonexistingeffortsandinnovativethinking;
Promotealignment(withinthecommercialsector,aswellasacrossthepublicandcommercial
sectors)inbothdesignandoperationalapproach;
Findabalancebetweenalignment/consistencyandflexibility/innovation;
Strikeabalancebetweenshorttermrealismandlongtermaspirations;and
Recognizethattherecommendationswillbeviewedwithinthecontextofanevolvinghealthcare
systemenvironment,acknowledgingtheeffectsofMACRAandotherCMSinitiatives.
InconveningtheCEPWorkGroup,theGCstipulatedthattheWorkGroupshouldtakecertain
considerationsintoaccountastheyexploredopportunitiestoadvancethealignmentandadoptionof
episodebasedAPMs.Indevelopingitsrecommendations,theGCnotedthattheCEPWorkGroup
shoulddevelopalistofpriorityareasthattogetherreflectabroadspectrumofpotentialepisodetypes,
representadiverserangeofpatients,andhavethepotentialtobewidelyadoptableandusefulacross
theentireU.S.healthsystem.TheWorkGroupusedthecriteriainFigure2toprioritizethediseasesand
conditionsonwhichtheirworkwouldfocus.
Figure2:CriteriaforPrioritization
Basedontheseconsiderations,theCEPWorkGroupagreedtofocusonthefollowingthreepriority
areas:
Electivejointreplacement;
Maternitycare;and
Coronaryarterydisease.
TheCEP
WorkGroup
chosethesethreepriorityareasbecause
theyhavethegreatestpotentialtocreate
agreaterconsensusandalignment
ofpaymentmethodsacrosspayersand,overtime,
toacceleratethe
adoptionofclinicalepisodebasedpayments.
KeyPrinciples
BeforetheCEPWorkGroupset
outtodevelopitsrecommendations,themembersdevelopedasetof
keyprinciplestoguide
theirassessmentofmodelscurrentlyinuse.Theseprinciplesalignwiththe
broaderset
ofprinciplesdescribedin
theLANAPMFrameworkWhitePaper.Theyare,however,
focusedspecificallyonthe
designofepisodepayments.Inaddition,
intheirresearchand
discussion,the
CEPWorkGroupchoseclinicalareasinwhich
clinicalepisodepaymentin
particularcouldalsoachieve
oneormoreofthefollowing:
Incentivizepersoncenteredcare:One
intendedeffectofAPMs(andaprinciple
oftheLANAPM
Framework1)istodeliver2personcenteredcare,definedashighqualitycarethatisevidencebased,
deliveredinanefficientmanner,andwherepatientsandcaregiversindividualpreferences,needs,and
valuesareparamount.Recognizing
thatpaymentreformmustultimatelyservetheinterestsof
consumersandpatients,theLAN
GuidingCommitteeendorsedasetofPrinciplesforPatientand
FamilyCenteredPayment.Theseprinciples,preparedbytheLAN
ConsumerandPatientAffinityGroup,
areintendedasguideposts
sothatnew
paymentmodelsandimplementationactivitiescanaddressthe
needsandprioritiesofpatientsandfamilies.TheprinciplesarereflectedinthisWhitePaper,andtheir
text
isincluded
in
Appendix
J.
Improve
patientoutcomesthrough
effectivecarecoordination:
Episodepaymentencouragesproviders
tobettercoordinatecareacrossandwithincaresettings,andtofocusmorestronglyoncarequality
to
achievebettercare,smarterspending,andhealthier
people.Effectivecarecoordinationisparticularly
importantforthosewith
chronicconditionsandforotherhighrisk/highneedpatients.
Rewardhighvaluecare:AnotherintendedeffectofAPMsistorewardhighvaluecareby
incentivizing
providersandpatients,togetherwiththeirfamilycaregivers,todiscussthe
appropriatenessofservices,
including
certainprocedures.Inthis
way,servicesthatdonotalignwithpatientpreferencescanbe
avoided.
Reduce
unnecessarycosts:Reducing
unnecessarycoststo
thepatientandtothehealthcaresystemis
anotherintendedeffectofAPMs.Episodepaymentoffersincentivestoexamine
allthe
costdrivers
acrosstheepisode,includingfragmentation,duplication,siteofservice,volumeofservices,andinput
costs/prices.Episodepaymentcancreateanapplestoapplescomparisonforassessingqualityand
1Principle1oftheAPMFramework
2DefinitionofPatientCenteredCare(APMFrameworkWhitePaper,page4)
cost(forpayersandconsumers).Thiswelldefinedproductallowsbuyerstocomparepriceand
quality.
RecommendationsFramework:DesignandOperations
TheWorkGroupsrecommendationsfallintotwocategories:
DesignElements:Thedesignelementsaddressquestionsstakeholdersmustconsiderwhen
designinganepisodepaymentmodel,includingthedefinition,thedurationoftheepisode,and
whatservicesaretobeincluded(Figure3);and
OperationalConsiderations:Operationalconsiderationsrelatetoimplementinganepisodepayment
model,includingtherolesandperspectivesofstakeholders,datainfrastructureissues,andthe
regulatoryenvironmentinwhichAPMsmustoperate.Operationalconsiderationsshouldnotbe
assessedinavacuumsincetheyareinterrelatedwiththedesignelementdecisions.
Figure3:EpisodePaymentDesignElementsandOperationalConsiderations
Thispaperisorganizedaccordingtothefollowingstructure:
SummaryofEpisodeDesignElementRecommendationsforelectivejointreplacement,maternity
care,andcoronaryarterydisease;
Achapteroneachofthethreeepisodesthatprovidesmoreindepthdiscussionon1)whythe
clinicalfocusareaisappropriateforapplyingepisodepaymenttoachieveimprovementsinquality
andoutcomes;and2)thethinkingbehindeachofthetendesignelementrecommendations;and
Achapteronoperationalconsiderations(stakeholderperspectives,datainfrastructure,and
regulatoryenvironment)thatcutacrossthethreeclinicalepisodepaymentmodels.Alsoincludedin
thischapterisadiscussionofquestionsandissuesthatmayariseinthecourseofimplementing
clinicalepisodepaymenttogetherwithanotherAPM,namely,populationbasedpayment.
10
Insertcoverpage
11
Chapter2:SummaryofEpisodeRecommendations
TheCEPWorkGroupconductedresearchandanalysisonarangeofexistingepisodepaymentinitiatives.
Basedontheirexperienceandtheanalysisofcurrentinitiatives,theWorkGroupidentifiedasetof10
episodepaymentmodeldesignelements(Figure3).Theseelementsreflectthedecisionsthatpayers
andprovidersneedtomakepriortoimplementation.Thetablesbelowsummarizethe10
recommendations,basedonthedesignelementsthatarediscussedinthisWhitePaper.
Table1:SummaryofJointReplacementEpisodeRecommendations
Episode
Definition
Theepisodeisdefinedasanelectiveandappropriatetotalhiportotalkneereplacementdue
toosteoarthritis.
Episode
Timing
Theepisodeshouldstartpreprocedure(e.g.30days),andend90dayspostdischargeinorder
toincludethemostresourceintensiveaspectsofcareforelectivejointreplacementpatients.
Accountabilityforfunctionalimprovementandperformancemeasurementgoesbeyond90
days.
Patient
Population
Theepisodeshouldapplytothebroadestpossiblepoolofpatients,usingriskandseverity
adjustmenttoaccountforageandcomplexity.
Services
Allservicesneededbythepatientthatarerelatedtothejointreplacementprocedureshould
becoveredbytheepisodeprice.
Requireuseofshareddecisionmakingandpatientengagementtools,transparencyof
Patient
Engagement performanceandthepaymentmodel,sharedcareplanning,accesstofullhealthrecords,care
coordination,andpatientreportedqualitymeasuresinpatientfacingmaterialstomaximize
opportunitiestoengagepatientsandfamiliesinadvancinghighvaluecare,bothfor
themselvesandoverall.
Accountable Theaccountableentityshouldbechosenbasedonreadinesstoreengineerchangeintheway
careisdeliveredtothepatientandtoacceptrisk.Inthismodel,theaccountableentitywill
Entity
likelyrequireadegreeofsharedaccountability,giventhenumberofcliniciansworkingtocare
forapatient.
Payment
Flow
Theuniquecircumstancesoftheepisodeinitiativewilldeterminethepaymentflow.Thetwo
primaryoptionsare:1)aprospectivelyestablishedpricethatispaidasonepaymenttothe
accountableentity;or2)upfrontFFSpaymenttoindividualproviderswithintheepisodewith
retrospectivereconciliationandapotentialforsharedsavings/losses.
Episode
Price
Theepisodepriceshouldstrikeabalancebetweenproviderspecificandmulti
provider/regionalutilizationhistory.Thepriceshould:1)acknowledgeachievableefficiencies
alreadygainedbypreviousinitiatives;2)reflectalevelthatpotentialproviderparticipantssee
asfeasibletoattain;and3)includethecostofservicesthathelpachievethegoalsofepisode
payment.
Thegoalshouldbetoutilizebothupsiderewardanddownsiderisk.
Typeand
LevelofRisk Transitionperiodsandriskmitigationstrategiesshouldbeusedtoencouragebroadprovider
participationandsupportinclusionofasbroadapatientpopulationaspossible.
Quality
Metrics
Prioritizeuseofmetricsthatcapturethegoalsoftheepisode,includingoutcomemetrics,
particularlypatientreportedoutcomeandfunctionalstatusmeasures;usequalityscorecards
totrackperformanceonqualityandinformdecisionsrelatedtopayment;andusequality
informationandothersupportstocommunicatewith,andengagepatientsandother
stakeholders.
12
Table2:SummaryofMaternityCareEpisodeRecommendations
Episode
Definition
Theepisodeisdefinedtoincludethelargemajorityofbirths,includingthenewborncare,that
arelowerrisk.Whilenotnecessarilylowerrisk,episodepaymentmayalsobeconsidered
appropriateforwomenwhomaybeatelevatedriskduetoconditionsthathavedefinedand
predictablecaretrajectories,suchasgestationaldiabetes.AstheCEPmodelmatures,some
groupswithsignificanthighriskpregnancyexperienceandcapacitymayseektomanagethe
entirecontinuumofrisk.
Episode
Timing
Theepisodeshouldbegin40weeksbeforethebirthandend60dayspostpartumforthe
woman,and30dayspostbirthforthebaby.
Patient
Population
Theepisodeshouldprimarilyincludethelargemajorityofbirths,includingnewborncare,that
arelowerrisk.TheWorkGroupalsosupportsCEPforwomenwhomaybeatelevatedrisk
becauseofpredictableriskfactorsthathavedefinedcaretrajectories,suchasgestational
diabetes.
Services
Coveredservicesincludeallservicesprovidedduringpregnancy,laborandbirth,andthe
postpartumperiod(forthewomen)andnewborncareforthebaby.Exclusionsshouldbe
limited.Initiativesshouldalsoconsiderincludinghighvaluesupportservices,suchasdoula
careandprenatalandparentingeducation.
Engagingwomenandtheirfamiliesiscriticalinallthreephasesoftheepisodeprenatal,
Patient
Engagement laborandbirth,andpostpartum/newborntocontributetothefoundationforhealthy
womenandbabies.
Accountable Theaccountableentityshouldbechosenbasedonreadinessto
reengineerchangeinthewaycareisdeliveredtothepatientandtoacceptrisk.Inthis
Entity
model,theaccountableentitywilllikelyrequireadegreeofsharedaccountability,giventhe
numberofcliniciansworkingtocareforapatient.
Payment
Flow
Theuniquecircumstancesoftheepisodeinitiativewilldetermine
thepaymentflow.Thetwoprimaryoptionsare:1)aprospectivelyestablishedpricethatis
paidasonepaymenttotheaccountableentity;or2)upfrontFFSpaymenttoindividual
providerswithintheepisodewithretrospectivereconciliationandapotentialforshared
savings/losses.
Episode
Price
Theepisodepriceshouldstrikeabalancebetweenproviderspecific
andmultiprovider/regionalutilizationhistory.Thepriceshould:
1) acknowledgeachievableefficienciesalreadygainedbypreviousinitiatives;2)reflectalevel
thatpotentialproviderparticipantsseeasfeasibletoattain;and3)includethecostofservices
thathelpachievethegoalsofepisodepayment.
Thegoalshouldbetoutilizebothupsiderewardanddownsiderisk.Transitionperiodsandrisk
Typeand
LevelofRisk mitigationstrategiesshouldbeusedtoencouragebroadproviderparticipationandsupport
inclusionofasbroadapatientpopulationaspossible.
Quality
Metrics
Prioritizeuseofmetricsthatcapturethegoalsoftheepisode,including
outcomemetrics,particularlypatientreportedoutcomeandfunctional
statusmeasures;usequalityscorecardstotrackperformanceonquality
andinformdecisionsrelatedtopayment;andusequalityinformationandothersupportsto
communicatewith,andengagepatientsandotherstakeholders.
13
Episode
Definition
Episode
Timing
Patient
Population
Services
Table3:SummaryofCoronaryArteryDiseaseEpisodeRecommendations
TheepisodeisdefinedascareforacohortofpatientswithdiagnosedCAD,fora12month
periodthatwillultimatelyalignwiththebenefityear(seeEpisodeTiming).Oncealignedwith
thebenefityear,theepisodewillcontinueforconsecutiveperiodsof12monthsofactivecare
managementforaslongasapatientisunderactivemanagementforCAD.PCIand/orCABG
proceduresdeemednecessaryduringanygiven12monthepisodeperiodwillalsobe
deliveredwithinanepisodepaymentmodel.
The12monthconditionepisodemaycommenceatvariouspointspostCADdiagnosis.Forany
nestedprocedurewithintheconditionlevelepisode,theprocedureepisodebegins30days
preprocedureandlasts3090dayspostdischarge.
Condition:PatientsdiagnosedwithCADandinsamehealthplanforfull12months.
Procedure:PatientsdeemedtoneedPCIorCABGbasedondeterminationofappropriateness.
Forboththeconditionandprocedureepisodes,theservicesshouldincludecoreservicesfor
CADmanagement(e.g.,lifestylechanges,medicationmanagement,andsecondary
prevention);andcoreservicesforthequalitydeliveryofaprocedure(e.g.,preoperative
diagnostics,drugsanddevices,caretransitionsupport,andpostacutecareincludingcardiac
rehab).
Patient
Modelsshouldsupportpatientandfamilyinvolvementinepisodepaymentdesign,
Engagement implementation,andevaluation,andpatientandfamilyengagementinallphasesofcardiac
care.Thisshouldbefacilitatedbyhealthinformationtechnology.
Accountable Theaccountableentityshouldbechosenbasedonreadinesstoreengineerchangeintheway
Entity
careisdeliveredtothepatient,andtoacceptrisk.Inthismodel,theaccountableentitywill
likelyrequireadegreeofsharedaccountability,giventhenumberofcliniciansworkingtocare
forapatient.
Payment
Flow
Episode
Price
Typeand
Level
ofRisk
Quality
Metrics
Theuniquecircumstancesoftheconditionlevel/nestedprocedureepisodemodelmakes
upfrontFFSpaymenttoindividualproviderswithintheepisode,withretrospective
reconciliationandapotentialforsharedsavings/risk,themorefeasibleoption.
provider/regionalutilizationhistory.Thepriceshould:1)acknowledgeachievableefficiencies
alreadygainedbypreviousinitiatives;2)reflectalevelthatpotentialproviderparticipantssee
asfeasibletoattain;and3)includethecostofservicesthathelpachievethegoalsofepisode
payment.
Thegoalshouldbetoutilizebothupsiderewardanddownsiderisk.Transitionperiodsandrisk
mitigationstrategiesshouldbeusedtoencouragebroadproviderparticipationandsupportas
broadapatientpopulationaspossible.
Prioritizeuseofmetricsthatcapturethegoalsoftheepisodeatboththeconditionand
procedurelevels.Theseincludeoutcomemetrics,patientreportedoutcomeandfunctional
statusmeasures,andsomeprocessmeasuresrelatedtoprocedures.Usequalityscorecardsto
trackperformanceonqualityandinformdecisionsrelatedtopayment.Usequality
informationandothersupportstocommunicatewith,andengagepatientsandother
stakeholders.
14
Insertcoverpage
15
Chapter3:ElectiveJointReplacement
Background:WhyUseEpisodePaymentforElectiveJointReplacement?
Totalhipandtotalkneereplacementsareamongthemostcommonlyperformedsurgicalprocedures
today.AccordingtotheU.S.CentersforDiseaseControlandPrevention,overonemillionsuch
proceduresareperformedeachyearacrossallpayers.Despitethehighvolumeofthesesurgeries,
outcomesandcostsofcareforjointreplacementsurgeriesvarygreatlyamongprovidersandacross
geographicareas(Table4).Thisvariation,combinedwithaclearcaretrajectory,theavailabilityof
qualitymeasures,andtheabilitytoempowerconsumers,madeitanidealfocusfortheCEPWorkGroup
todeveloprecommendations.
Table4:JointReplacementintheU.S.:Prevalence,Cost,andOpportunitiesforImprovement3
CommercialMarket
Medicare
Numberof
Procedures
In2011,thereweremorethan
645,000kneereplacementsand
morethan306,000hip
replacements(AmericanAcademy
ofOrthopaedicSurgeons,2014).
In2014,FFSMedicarecoveredmorethan400,000procedures(U.S.
DepartmentofHealthandHumanServices,2015).
Reasonfor
Procedure
Jointreplacementsaremostoften
duetoosteoarthritis.Hip
replacementsmayalsobedueto
fracture.
Jointreplacementsaremostoftenduetoosteoarthritis.Hip
replacementsmayalsobeduetofracture.
Spendingby
Payers
Kneereplacementcostsrange
from$11,317to$69,654.
In2014,onhipandkneereplacement,FFSMedicarespentmore
than$7billion(includingcostsharing)forthehospitalizationsalone
(U.S.DepartmentofHealthandHumanServices,2015).
Hipreplacementcostsrangefrom
$11,327to$73,987(BlueCross
BlueShieldAssociation&Blue
HealthIntelligence,2015).
Thedatainthistableincludesbothelectiveandnonelectivejointreplacement,aswellasjointreplacements
conductedforreasonsotherthanosteoarthritis.
16
Medicare
CommercialMarket
Variationin
Cost
Thecostofajointreplacementprocedurecanvarybytensof
thousandsofdollars,dependingonthegeographiclocation.
Medicareexpendituresfor
surgery,hospitalization,and
postacuterecoveryrangefrom
$16,500to$33,000,across
geographicareas(U.S.
DepartmentofHealthand
HumanServices,2015).
Variationcanoccurwithinthesamemetropolitanmarket.For
example,inDallas,akneereplacementcancostanywherefrom
$16,000to$61,000,dependingonthehospital.InBoston,ahip
replacementcancostanywherebetween$17,000and$73,987.
Astudyof64marketsintheU.S.foundthatcostscanvaryupto
313%(BlueCrossBlueShieldAssociation&BlueHealth
Intelligence,2015).
Factors
Affecting
Variation
between
Commercial
Marketand
Medicare
Duplicationofexams,imaging,andotherdiagnosticsduetolack
ofcommunicationbetweenthesurgicalpracticeandthe
hospital.
Siteofservice;i.e.performingtheprocedureinaninpatient
hospitalsettingwhenalesscostlyoutpatientsettingwouldbe
deemedsafeandappropriateforagivenpatient.
Variationinthepricepaidforinpatientlengthofstay.
Delaysand/orlackofcoordinationintransferringpatientsfrom
hospitaltopostacutecare(homehealth,outpatientor
inpatientrehabilitation,orskillednursing).
Variationinvalueandcostofservices,technology,equipment,
andimplants.
Variationintheuseofstandardizedcareprotocols.
Variationin,andunnecessaryuseof,highintensity,postacute
care(PAC).
Source:TheMITRECorporation.
Medicare,Medicaid,largepurchasers,commercialpayers,andprovidershavealldevelopedclinical
episodepaymentstrategiesforhipandkneejointreplacementin anefforttoreducevariationandthus
positivelyaffectoverallcostsandvariation.Asdescribedinin AppendixC:SummaryofJoint
ReplacementInitiativesReviewed,jointreplacementepisodepaymenteffortstendtocorrelatewith
reduceduseofnonvalueaddedcare,suchasunnecessarypostacutecare,lengthyinpatienthospital
stays,avoidablecomplicationsandreadmissions,allofwhichtogethercontributetobetteroutcomes
andexperiencesandlowertotalepisodecosts.
Recommendations:ElectiveJointReplacement
ThedesignelementrecommendationsreflecttheCEPWorkGroupsresearchandanalysisonarangeof
existingepisodepaymentinitiativesforjointreplacement(see AppendixC).SeeChapter2,Episode
PaymentDesignElements,forasummaryoftherecommendationsdescribedin moredetailbelow.
17
1. EpisodeDefinition
Theepisodeisdefinedasanelectiveandappropriatetotalhip
ortotalkneereplacementduetoosteoarthritis.
Therecommendationsinthischapterarebasedondefiningtheepisodeasatotalhiportotalknee
replacementprocedure4thatisbothelectiveandappropriate.
Elective:Thereareanumberofreasonswhythisepisodeisdefinedaroundelectivetotalhipand
electivetotalkneereplacement.Comparedtolowerextremityjointreplacementduetofracture,
electivejointreplacementishighervolumeandmorepredictable.Focusingonelectivejoint
replacementthenprovidesahighervaluetargetthanfocusingonanepisodethatincludesfractures
andemergencyjointreplacement.Itisalsoamorecontrolledclinicalevent,inwhichtherearegreater
opportunitiesforpatientengagementandshareddecisionmaking.Inaddition,thepreoperativeand
postdischargecaretrajectoriesforelectivejointreplacementhaveanevidencebaseandarewell
standardized,whichcaneasethewayforwideadoptionofthisepisodemodel.Finally,anelective
procedurecreatestheopportunityforpatientsandproviderstohaveameaningfuldiscussionabout
whethertheprocedureistrulyappropriate,and/orwhethertherearealternativetreatmentsthatwould
bettersuitthepatientsgoalsandvalues.
Appropriate:Asnotedpreviously,jointreplacementisamongthemostcommoninpatientsurgeriesin
theUnitedStates,andsomeestimatethatthedemandforthisprocedurewillquadrupleby2030
(Ghomrawi,Schackman,&Mushlin,2012).Findingdataonhowmanyofthosejointreplacement
procedureswereelectiveandappropriate,however,isnotasstraightforward.Stakeholdersseejoint
replacementasaprimeopportunityforapplyingappropriatenesscriteriainthecourseofdetermining
whetherornotitshouldbeperformed,orwhetheralternative,lessinvasivetreatmentsarepreferredby
thepersonwithosteoarthritisthatcanachievesimilarorbetterfunctionaloutcomesatlowercosts.
Whenappropriatenesscriteriawereappliedinothercountries,studiesfoundthat20%to40%of
electivejointreplacementprocedureswereconsideredinappropriate,whenusingevidencebased
criteria(Quintanaetal.,2008;VanWalravenetal.,1996).Themodeldescribedhereisdesignedto
includeonlythosepatientsforwhomthedecisiontohaveanelectivejointreplacementisevidence
basedand,consistentwithpatientpreferencesandvalues.
Appropriatenesswillbedeterminedviaboththeuseofafunctionalstatusassessmenttoolanda
meaningful,validated,shareddecisionmakingprocess:
1. Evidencebasedfunctionalstatusassessment:Forapatienttobeincludedintheepisode,there
shouldbeevidencethatinadditiontoaclinicalassessment,aproviderusedastandardized,
validatedfunctionalstatusassessmenttooltodeterminethatthepatientisanappropriate
Theepisodedefinitiondoesnotincludepartialkneereplacementsorpartialhipreplacementduetotheirlow
volumeintheMedicarepopulation.Organizationsthatwanttopursueaddingtheseprocedurestotheepisode
shouldbeawarethatthecostisoftenhigherthanthecostfortotalreplacement,whichwillfactorintotheepisode
price.
18
candidateforasurgicalprocedure,asopposedtobeingacandidateforlessinvasivecaresuch
asweightloss,activitymodifications,nonsteroidalantiinflammatorymedications,and
exercise.Theassessmentshouldlooknotonlyatthefunctionalcapabilityofapatientshipor
knee,butalsothepainthatthepatientisexperiencing,optimizationofmodifiableriskfactors
(suchasobesity,smoking,opioidtolerance,untreateddepressionoranxiety,and/orpoorly
controlleddiabetes).Itshouldalsoincludeanassessmentofwhethertheprocedurewill
meaningfullyaffectbothfunctionandpainlevels.
ExamplesofFunctionalStatusAssessmentTools
Someexamplesofprovideradministeredfunctionalstatustoolsare:
WesternOntarioandMcMasterUniversitiesArthritisIndex(WOMAC)score;
HipDisabilityandOsteoarthritisOutcomeScore(HOOSJR);
KneeInjuryandOsteoarthritisOutcomeScore(KOOSJR);
PatientReportingOutcomeMeasurementInformationSystem(PROMIS);and
VeteransRAND12itemHealthSurvey(VR12).
2. MeaningfulSharedDecisionMaking:Inadditiontoformalassessmentofpainandfunctional
status,theremustbeevidencethatthepatient,possiblywithafamilycaregiver,hasworked
throughadecisionaidthatishighlyratedaccordingtoInternationalPatientDecisionAids
Standards(IPDAS)withthesupportofadecisioncoachorahealtheducator,ifneeded(Ottawa
HospitalResearchInstitute,2014a).OneexampleofadecisionaidproviderisHealthwise,anot
forprofitcorporationthatprovidesconsumerhealthinformationtopatientsandcaregivers,
whichhashighlyrateddecisionaidsforbothhipandkneereplacement,asassessedbythe
IPDAS(OttawaHospitalResearchInstitute,2014b;OttawaHospitalResearchInstitute,2014c).
Healthwiseincludesinformationaboutcareoptionsincludingtheprosandconsofeachand
howtoconsiderapatientsvaluesandpreferencesastheyrelatetothecareoptions.
Inadditiontoaninitialshareddecisionmaking,thereshouldbeevidenceofongoing
engagementofpatientsinthediscussionofcareoptionsandsubsequentdecisionsrelatedto
thejointreplacementprocedure,ifoneisdeemedappropriate.Primarycareproviderscan
performthisrole,andindoingso,providegreatercontinuityofcaretotheirpatients.These
providerscouldalsosupportpatientsinreviewingcomparativequalityinformationaboutchoice
ofsurgeon,surgicalfacility,rehabservices,andhomehealthservicesatatimewhenthepatient
stillhavetimetomakeproactivedecisionsabouthisorhertreatment.
Ideally,bothoftheseprocessesshouldbeintegratedintodiscussionswithpatientsabout
appropriatenessofcare,andpatientsshouldbeabletoweighinwiththeirownvaluesaboutthe
potentialrisksandbenefitsofthetreatmentoptions.
TheImplementationResources(AppendixF)includesinformationonAppropriateUseCriteria
developedbyorganizationssuchastheAmericanAssociationofOrthopedicsurgeons.Providersand
payerswillneedtodeterminehowbesttoapplyappropriatenesscriteriawhileavoidingthepotential
forlimitingnecessarycare.
19
Finally,whilefunctionalstatusassessmentsandcoaching/educationarecriticaltomakingtheinitial
determinationthataprocedureisnecessaryandappropriate,theseareactivitiesthatshouldoccur
acrossthecontinuumofcaretoensurethatcareishavingtheintendedeffectandthatpatients
preferencesarereflectedinthecourseofcare.
2. EpisodeTiming
Theepisodeshouldstartpreprocedure
(e.g.30days),andend90dayspostdischarge(Figure4)inordertoincludethemost
resourceintensiveaspectsofcareforelectivejointreplacementpatients.Accountability
forfunctionalimprovementandperformancemeasurementgoesbeyond90days.
Figure4:EpisodeTiming
StartandEndPoints
Optimally,thestartandendpointsshouldbeestablishedbasedonthetimewhenunwarranted(i.e.not
evidencebased)variationincarebeginsandendsandwhentheopportunitytoimpactqualityand
outcomesisgreatest(Figure4).Whiledefiningstartandendpointsisnecessary,incentivescanbe
createdforservicestobescheduledeitherbeforeorafterthedatesinordertoimprovepatient
outcomesanddecreasethecostsoftheepisode.Therefore,ananalysisofutilizationpatternsand
outcomesshouldbebuiltintothedataanalyticsandmonitoredfrequentlyinordertoensurethat
patientcareisnotinappropriatelyaffected.
EpisodeStartPoint:Theepisodeshouldbeginpreprocedure(asopposedtostartingatthepointof
procedure),inordertocreateanincentiveforreducingunnecessaryorduplicativeimagingandother
diagnostics.Thecriticalissuewhendeterminingtheepisodestartpointisensuringthatitprovidesan
appropriateamountoftimetoachievethisgoal,withoutcreatingperverseincentivestooverorunder
deliverappropriatepreoperativecare.Alternatively,theepisodedesigncouldincludecarethatisnot
directlyrelatedtotheprocedure.Basedonthedesignofcurrentinitiatives,areasonablestartingpoint
20
maybe30dayspreprocedure.Operationally,thisrequirescreatingalookbackperiod,whichan
electiveprocedurebydefinitionmakesfeasible.
Animportantfactortoconsiderwhensettingthestartpointisthepatientpopulation.Olderadultsand
Medicarebeneficiariesmayneedadifferenttimewindowthantheiryoungercounterpartswhoare
coveredbycommercialinsurance.
EpisodeEndPoint:Thelengthoftheepisodeaftersurgeryisacriticaldecisionpoint.Thisisbecause
poorpostdischargecarecoordinationaroundauxiliaryservicessuchaspostacutecare,rehabilitative
treatment,homeandcommunitybasedservicesandsupports,andevendeliveryofmedicinescanbea
significantcontributortocostsandreducedpatientoutcomes.Basedontheprinciplethattheepisode
designshouldbepatientcentered,andacknowledgingthechallengespatientsexperienceduringthe
rehabilitationperiod,therecommendationisfortheepisodetoend90dayspostdischarge.Even
thoughcostsmaynotvaryasmuchinthelatterdaysoftheepisode,theriskofsignificantcomplications
continuesthroughoutthe90days;infact,formanypeople,therecuperationperiodoftenexceedsthat
timeperiod.
Currentmodelsfeatureendpointsthatvaryfrom30daysto90days.Thisrecommendationbalances
theabilityoftheaccountablepartytohavesomecontroloverthepatientscare(whichwouldsupporta
shorterepisode)withtherecognitionthatpatientscanbenefitenormouslyfromprofessionalsupportin
coordinatingclinicalandotherpostoperativeservicesduringrecovery,whichextendswellbeyond30
dayspostdischarge.Onefactortoconsiderindeterminingepisodelengthisthespecificityofthe
definitionoftheepisode,includingtheinclusionsorexclusions,asthemorenarrowlyitisdefined,the
morecomfortableproviderswillbewithalongerepisode.
Accountability:Qualitymeasurementmayincludedataforupto12monthspostdischarge,even
thoughtheepisodepaymentperiodends90dayspostdischarge.
3. PatientPopulation
Theepisodeshouldapplytothebroadestpossiblepoolofpatients,
usingriskandseverityadjustmenttoaccountforageandcomplexity.
Stakeholderviewsonwhichpatientsshouldbeeligiblefortheseepisodesmayvarysignificantly.Within
thecontextofelectivejointreplacement,thepatientpopulationtowhichtheepisodepaymentapplies
shouldbebroad.
Ideally,focusingonabroadpopulationwithinthecontextofelectivejointreplacementwillalso
motivateinnovationsincareandcarecoordinationthatwillbenefitthehighestriskpatients,whoare
alsohighestinresourceuse.Appropriatelyspecifiedriskandseverityadjustmentalgorithmsappliedto
theepisodepricearecriticaltothisrecommendationiftheepisodeistogainbuyinfromproviders.
Itmayalsobeusefultoenlistthesupportoftheprimarycareprovidertoensuretheproposedsurgery
episodeisintegratedwithinthecontextofthepatientsotherhealthconcerns.Itisalsovaluableto
engagethefamilyinshareddecisionmaking.
21
Ifconcernsariseregardingtheappropriatenessdecision,anappealsprocessshouldbeestablishedfor
thosepatientswhosecircumstancesorriskcannotbeidentifiedthroughavailabledataandmightnot
otherwisebeeligible.Itisimportanttoacknowledgethatineligibilityfortheepisodedoesnot
necessarilymeanthepersonwouldnotreceivecare;theircarewouldsimplynotbeincludedinthe
episodepaymentinitiative.ThisdesignwillsupporttheLANsgoals,whileatthesametimediscouraging
providersfromcherrypickingthelowestriskpatients.Aflipsidetocherrypickingisthe
inappropriateselectionofcaseswhereconservativemanagementisamoreappropriatealternativeto
surgery.
4. Services
Allservicesneededbythepatientthatarerelatedtothejointreplacement
procedureshouldbecoveredbytheepisodeprice.
Stakeholderviewsonwhichservicesshouldbeincludedmayvarysignificantly.Payersmaywantto
definetheepisodemorebroadlytocaptureasmuchvariationand,thus,potentialefficienciesas
possible.Providers,ontheotherhand,mayprefermorenarrowlydefinedepisodessothatcareneeds
andtheassociatedcoststhatarecompletelyunrelatedtototalhiportotalkneereplacementdonot
weighintothetargetpriceorqualitymetricgoalsfortheepisode.Forexample,apatientwhoreceivesa
totalkneereplacementandrequiresacoronaryarterybypassgraft(CABG)procedurewithinthe90days
postjointreplacementdischargewindowshouldnothavethecostsoftheCABGassociatedwiththe
jointreplacementepisode.Toonarrowanepisodedefinition,however,mightmakethecostsof
implementationascomparedtothevaluecreatednotworththeeffort.
ThispaperdoesnotincludespecificMSDRGcodestoguidetheselectionofincludedservicebecause
thetworelevantDRGcodes(469and470)applytoalllowerextremityjointarthroplastyproceduresand
specifyonlythoseproceduresperformedinaninpatienthospitalsetting.Thus,usingthesecodesto
definetheservicesincludedintheepisodemay1)resultinincludingpatientsthatdonotmeetthe
patientpopulationorepisodedefinitioninthismodel;and2)excludeoutpatientprocedures,whichis
nottheintent.
IncludedServices:Theepisodepaymentshouldincludedeliveryofallservicesbilledinthedefinedtime
periodthatarerelatedtotheelectivejointreplacementprocedure. Mostinitiatives(AppendixC)include
allrelatedservicesthatoccurwithinthedefinedtimeframe,including,butnotlimitedtocostsinvolving
physicians,hospital/ambulatorysurgicalcenters,devices,labs,homehealthservices,skillednursing
facilities,physicaltherapy,andsometimespharmaceuticals.Includingpharmaceuticalsanddevicesin
theepisodepriceanddefinitionisimportantbecausetheycanbeanexpensiveportionofthebundle.
Therearetwoapproachestodeterminingwhichservicesareconsideredpartoftheepisode:
DefinetheExcludedServices:Oneapproachfocusesondefiningalistofexcludedservices.Forexample,
exclusionsfromtheComprehensiveCareforJointReplacement(CJR)Modelfinalruleinclude
hemophiliaclottingfactorsfurnishedduringtheinpatienthospitalization,andacutesurgeryfor
unrelatedconditions,suchasappendectomy(MedicareProgram;ComprehensiveCareforJoint
ReplacementPaymentModelforAcuteCareHospitalsFurnishingLowerExtremityJointReplacement
22
Services,2015).TheseexcludedservicesareidentifiedbasedonMedicareSeverityDiagnosisRelated
Groups(MSDRGs)andInternationalClassificationofDiseasesClinicalModification(ICDCM)diagnosis
codes.Ifaninitiativefocusessolelyonexclusions,recognizethatthelistislikelytobeextremelylongto
avoidsituationswherebypatientsorprovidersdelayimportantservicesuntilaftertheepisodeends.For
example,ifpreventiveservicescannotbedelayedsimplybecausetheyareduetobeperformedduring
theepisodeofjointreplacementandtheyarenotspecificallyexcluded,thosecostswouldbeconsidered
partoftheepisodecosts.
DefinetheIncludedServices:Othermodelsrelyonveryspecificlistsofincludedservicesandexclude
anythingnotonthatlist.Definingwhatisincluded,ratherthanexcluded,mightbemoreeffectiveand
easiertomanage.Payersandprovidersshouldlooktoexistingresourcesthatprovideevidencebased
informationaboutserviceinclusionsandexclusions.
PatientswithMultipleConcurrentConditions:Onechallengeinestablishingserviceboundariesishow
todealwithcomplexpatientswithmultipleconcurrentconditions.Forexample,apatientwithdiabetes
andcoronaryarterydiseasewhoreceivesajointreplacementmayalsorequireadditionalservices
relatedtotheirchronicillnesswithinthe90dayepisodeperiod.Whilesomeofthoseservicesmay
clearlybeoutsidethescopeofthekneeorhipreplacement,others(e.g.,treatmentforapostopheart
attack)maybelessclear.
Thesignificantriseinjointreplacementsamongpatientswhoareobeseandhavecomorbidconditions
suchasdiabetesandheartdiseasemakesthisasignificantconcernforpayersandproviders.Whilerisk
adjustmentmayaddressthisinpart,itisnecessarytoincludesufficientaccountabilitywithinthe
episodesoastoappropriatelycareforcommoncomplicationssuchasmyocardialinfarction,infection,
deepveinthrombosis,etc.Thesearewithinthepurviewoftheaccountableentityiftheappropriate
involvementoftheprovidersresponsiblefortheongoingcareoftheseconditionsisobtained
throughoutthetimeframeoftheepisode.Forexample,thetightcontrolofdiabeteshasbeenshownto
decreasetheriskofthesesamecomplications.
5. PatientEngagement
Requireuseofshareddecisionmakingandpatientengagementtools,
transparencyofperformanceandthepaymentmodel,shared
careplanning,accesstofullhealthrecords,carecoordination,
andpatientreportedqualitymeasuresinpatientfacingmaterials
tomaximizeopportunitiestoengagepatientsandfamiliesinadvancing
highvaluecare,bothforthemselvesandoverall.
AsdetailedinRecommendation1(EpisodeDefinition)andRecommendation2(EpisodeTiming),the
episodepaymentmustbedesignedinawaythataddsvalueforpatientsandtheirfamiliesand
determinesthebestcourseofcare.Tosummarize,accountableentitiesmustprovide:
Evidencethataproviderusedastandardized,validatedfunctionalstatusassessmenttoolto
determinethatthepatientwasanappropriatecandidateforatotalhiporkneereplacement;and
23
Evidencethatthepatient,possiblyalongwitha
familycaregiver,workedthroughahighquality
decisionaid,withadecisioncoachornurse
educator,asneededanddesired.
Inaddition,patientsandfamilycaregiversshouldbe
providedthefollowinginanonbiasedand
transparentmanner:
ComparativeProviderQualityInformation:
Patientsandfamilycaregiversshouldhaveaccessto
informationabouttheprocedurerelated
complicationratesofpossiblesurgeonsand
possibleacutecarefacilities;outcomessuchas
reductioninpain,gainsinfunctionalstatus,and
qualityoflife;andinformationonthequalityof
possiblepostacutecarefacilitiesandhomehealth
agencies.Patientsshouldreceivehelpshortlyafter
decidingtohaveaprocedureinidentifying
participatingsurgeons,facilities,andagencies,and
infindingandinterpretingrelevantinformation
aboutthem.Suchhelpshouldbeavailablethrough
clearlydesignatedpersonnelwithoutconflictsof
interest.Itisoptimalforthepatienttolearnabout,
visit,andassessthequalityandsuitabilityofpost
acutecareoptions,includinghomehealth,skilled
nursingfacilities,andinpatientrehabilitation
facilities,priortoadmissionforsurgery.Inaddition,
theaccountableentityshouldidentifyproviders
includedinthemodelandprovidethatlistto
patients.
DeployingSharedDecisionMakingToolsina
WaythatisMeaningfulforPatientsand
FamilyCaregivers
Meaningfulshareddecisionmakingrequires
bothhighqualitydecisionaidsandaprocess
thatsupportstheiruse.Thisprocesscanbe
describedviathefollowingsteps:Theseaids
supportprovidersandpatientsindiscussing
thefollowing:
1) Acknowledgingthatthereisadecisionto
bemade;
2) Explainingthattherearecareoptions,
andeachoptionhasadifferentsetofissues
toconsider;
3) Presentingthebestevidenceaboutthe
prosandconsofthecareoptions;and
4) Acknowledginghowpersonalvaluesand
preferencesmightalignwiththecare
options.
Thisconversationshouldbefollowedbya
subsequentopportunityforthepatientand
familycaregivertomeetwiththecare
providertogetanswerstoanyquestions,
decideabouttheoptimalpathforward,and
initiatesharedcareplanning.
ReimbursementTransparency:Patientsandfamilycaregiversneedtransparentinformationonhow
providersarebeingreimbursedinanepisodepaymentmodel;theimpactthatepisodepaymentmay
haveonthepatientscopayandcoinsuranceresponsibilitiesandothercostsharing;andthemannerin
whichcarewillbedelivered.
CoordinationAcrossCareSettings:Intheprivatesector,thismaymeanengagingwithpatientsand
familycaregiversaboutinoroutofnetworkpostacuteorfollowupcare.IntheMedicareFFS
program,thismayinvolvediscussionsrelatedtochoiceofpostacuteproviders,afterconfirmingthat
thepatientsstillhavefreedomofchoice.Regardlessofpayer,thisinvolvesprovidersandpatients
workingtogethertoidentifyparticipatingandaccessiblepostacutecareoptions,understandingtheir
qualityratings,andmakingawisechoice.Thisisacriticalpatientconversationasitmaybethecasethat
apatientwillnotwishtoseeaproviderthatiswithinaspecifiedpaymentarrangement.
SupportedCarePlanning:Providersshouldincorporatesharedcareplanningintothedeliveryofcare,
whichincludescollaborativeproviderpatientgoalsettingpriortotheprocedureandongoingdecision
makingandmonitoringusingdocumentedindividualizedcareplansthatareaccessibletobothpatient
24
andproviders.Patientswithcomorbidconditionsthatmayaffecttheiroutcomeshouldbeencouraged
toengagetheirprimarycareproviderintheirdecisionmakingprocess.
AccesstoHealthCareInformation:Forpatientengagementtooccur,patients(and,asdesired,family
caregivers)shouldhavefullaccesstohealthrecordstohelpunderstandandmanagetheirconditionand
care.Thegoalistoprovideinfrastructureandsupportforgathering,storing,andusinghealthdata.One
exampleofatoolthatisprovidingaccesstothesedataisthesuccessfulOpenNotesproject,whichis
providingagrowingproportionofpatientstofullaccesstotheirelectronichealthrecords(Belletal.,
2015;Eschetal.,2016;Walker,Meltsner,&Delbanco,2015).
6. AccountableEntity
Theaccountableentityshouldbechosenbasedonreadinessto
reengineerchangeinthewaycareisdeliveredtothepatientandtoacceptrisk.
Inthismodel,theaccountableentitywilllikelyrequireadegreeofshared
accountability,giventhenumberofcliniciansworkingtocareforapatient.
OverallReadiness:Thequestionofreadinesstobothreengineerthecaredeliverymodelforthe
patient,andintheprocess,acceptthefinancialrisktheymightincur,iscentraltothedeterminationof
whatentityorentitiesshouldbeaccountable.Thereareanumberofkeyrequirementsneededfor
successregardlessofwhichentity(orentities)areheldaccountable(Table5).Payersshouldworkwith
theaccountableentitytoassesstheirreadiness,andpromotecollaborationtoallowformultiple
providerswithinanelectivetotaljointreplacementcareteamtosharetheriskandrewardinsucha
mannerthatallareengagedincreatingaseamless,efficient,patientcenteredcareprocess.Thisprocess
canrequireactiveparticipationacrossthecontinuumbyaligningincentivesacrosscontractsinthe
privatesector,becausethepayeroftenhascontractsdirectlywithproviders.Medicareallowsforfull
freedomofchoiceofproviderinFFS,andthespreadingofriskmaytaketheformofagainsharing
relationship.ThisisparticularlyimportantinarelationshipwherebytheprovidersarestillpaidaFFS
witharetrospectivereconciliation,becausetheaccountableentityhaslimitedabilitytoobtainbuyin
fromotherprovidersintheepisodewithoutdirectincentivesforthemtocollaborate.
FactorstoWeighinDeterminingReadinessforEpisodeAccountability:
Minimumvolumestandards;
Abilitytodeliver,orcontractfor,theentirebundleofservicestoberendered;
Demonstratedabilitytocarefortotaljointreplacementpatients;
Effectivedischargeplanningcapacities,includingsystemstoincluderehabilitationphysiciansand
extendersearlyinthedischargeplanningprocesstohelpinidentifyingthepropertrajectoryof
patientsandtheircare;
Abilitytomanagetransitionsorhandoffsfromonesettingtoanotherwhennecessary(e.g.entry,
transitions,anddischarge);
Abilitytotrackqualityindicatorsandpatientoutcomesacrossanarrayofservicesandsettings;
25
Demonstrateddedicationofthehospital,physicians,nurses,therapists,andotherclinical
professionalstimetotheprograms;
Capacitytomonitorpatientclinicalstatusandcoordinatemedicalmanagementandreconciliation
aspatientsprogressacrossacuteandpostacutecaresettings;
Abilitytocoordinatewithothercommunityservicestofosterthepatientsindependence;
Necessaryfinancialsystemstoadministerpaymentacrossmultipleentities;and
Abilitytotoleratefinancialrisk,includingpostdischargeoutcomes,suchasreadmissions,and
understanditsownriskexposure.
SharedAccountabilityAcrossaCareTeam:Anidealdesignwouldallowforsharedaccountabilityacross
multipleprovidersrepresentingpreoperative,surgical,andpostacutecare(Figure5).Theseproviders
includenotjustorthopedicsurgeonsworkinginaninpatientsetting,butalsocaresettingssuchas
emergencydepartments,ambulatorysurgicalcenters(ASCs),outpatienthospitals,skillednursing
facilities(SNFs),inpatientrehabilitationfacilities(IRFs),andotherPostAcuteCareproviders.Theymay
alsoincludeotherclinicianssuchashospitalistsandtelehealthclinicians.Regardlessofwhichentityis
determinedtobeultimatelyaccountable,theremustberecognitionthereareanumberofkey
requirementsneededforsuccess.Payersshouldworkwiththeaccountableentitytoassessitsreadiness
to:1)promoteandsupportcoordinated,collaborativecare;and2)allowformultipleproviderswithina
jointreplacementcareteamtosharetheriskandrewardinsuchamannerthatallareengagedin
creatingaseamless,efficient,patientcenteredcareprocess.Itisusefultorecognizethatpostacute
careentitiesmaybesetuptomeetthesecriteria.5
Intheprivatesector,thepayeroftenhascontractsdirectlywithproviders.Thus,thisdesign,inwhich
thereisoneaccountableentitybutmultipleproviderentitiesshareriskand/orreward,willrequire
activecoordinationacrossprovidersservingallpartsofthecarecontinuum.Itwillalsorequirean
alignmentofincentivesbythepayerortheaccountableentityacrossprovidercontracts,toallwork
towardasharedsavingsandhighqualityperformancegoal.Inthepublicsector,withapayersuchas
MedicarethatallowsfortraditionalMedicarebeneficiariesfullfreedomofchoiceofproviderinFFS,the
riskspreadingmaytaketheformofagainsharingrelationshipamongproviderswhohavereceiveda
Medicarewaiverthatallowsthemtodoso.Thisisparticularlyimportantinarelationshipwherebythe
providersarestillpaidFFSwitharetrospectivereconciliation,becausetheaccountableentityhas
limitedabilitytoobtainbuyinfromotherprovidersintheepisodewithoutdirectincentivesforthemto
collaborate.
TheCMSBundledPaymentsforCareImprovement(BPCI)Initiativeincludestwomodels(Model2andModel3)
thatincludePostAcuteCare,withModel3definedashavingthePACproviderserveastheaccountableentity.
26
Figure5:ExamplesofJointReplacementAccountableEntities,BasedonCareTeam
AbilitytoEngineerChange:Thepreprocedureorthopedicsurgeonmaybemostabletoeffectchange
inanelectivejointreplacementepisode,givenhisorherroleindeterminingappropriateness,and
engagingthepatientincareplanningandpostdischargePACdecisionmaking.However,assigning
accountabilitytotheorthopedicsurgeonmaynotbefeasibleinsomemarkets.Risklevelsmayvary
dependingontheattributesoftheaccountableentity.Whileitisimportantthatoneentitybethe
primaryaccountableparty,itisalsoimportantthatcareisprovidedusingateambasedapproach.
Payerscanusetheirnegotiationswithprovidersandusegainsharingandlosssharingtoenablea
systeminwhichallproviderswhotouchthepatientsharesomelevelofaccountability.Payerswillneed
toassesswhichproviderinagivenmarketcanactmosteffectivelyinachievingajointreplacement
episodepaymentinitiativesgoalsandestablishthatproviderastheaccountableentity.
Publicandprivatemodelsaremixed.Sometimesthehospitalistheaccountableentity,butsometimesit
isthephysicianpractice(oftentheorthopedicsurgeonorpractice).Inmanycases,thecliniciancanhave
thegreatestimpactoncareredesign,becauseestablishingaphysicianlevelchampioncaneasethe
episodesmanagementprocess.Thecliniciancanleadthedesignandimplementationofnewpatient
careprotocols;determinethebestprostheticdevices;andcommunicatewiththepatientspost
dischargeprovidermoreeasilythanthehospital.Further,thediscussionswithpatientsregarding
appropriatenessandexpectationsonfunctionalimprovementsaremosteffectiveifthephysiciansare
fullyengaged.
AbilitytoAcceptRisk:Somephysicianpracticesmayhavelessabilitytoassumedownsideriskthan
largerpracticesorotherbettercapitalizedproviders,suchashospitalsorhealthsystemsthatintegrate
hospitalandphysiciancare.Thislimitedabilityforphysicianpracticestotakeonriskcanbemitigatedby
limitingthelevelofriskassociatedwiththeepisode.Strategiesfordoingsoarediscussedinthenext
recommendation.
IntheCJRprogram(MedicareProgram;ComprehensiveCareforJointReplacementPaymentModelfor
AcuteCareHospitalsFurnishingLowerExtremityJointReplacementServices,2015),CMSdetermined
thatthehospitalincomparisontootherhealthcarefacilitiesisbestpositionedtomanagethecarein
aneffectivemanner.Thisisbasedontheideathathospitalshaveresourcestocoordinateandmanage
care,andhospitalstaffareinvolvedindischargeplanningandPACrecommendationsforrecovery.The
regulationsallowthehospitaltoopttoshareaportionofgainsorlosseswithotherprovidersthatare
27
partofthedeliveryofcareforpatients,includingphysiciansorotherpostacuteproviders.IntheAcute
CareEpisodedemonstrationimplementedbyCMS,whilethehospitalwastheaccountableentity,itwas
consideredcriticaltogetthephysiciansinvolved.Inthatinitiative,hospitalswereabletoutilizegain
sharingtoengagephysicians.
SeetheChapter6,OperationalConsiderations,foradiscussionon two relatedissues.First,inthedata
infrastructuresectionisadiscussionofthestructuresnecessarytofacilitatecoordinationand
communicationacrossmembersofthecareteamandbetweencliniciansandpatients.Second,inthe
regulatoryenvironmentsection,isthediscussionofhowstatelawsmayaffecthowmuchriskproviders
areallowedtoincur.Forexample,somestateslawsandregulationsaresupportiveofhospitalstoserve
astheaccountableentity,ratherthanaphysicianorphysicianpractice.
7. PaymentFlow
thepaymentflow.Thetwoprimaryoptionsare:
1) aprospectivelyestablishedpricethatispaidasonepaymenttothe
accountableentity;or2)upfrontFFSpaymenttoindividualproviders
withintheepisodewithretrospectivereconciliation
andapotentialforsharedsavings/losses.
Episodepaymentsaretypicallydispersedviaeitherprospectivepaymentorretrospectivereconciliation
(Figure6).
InProspectivePayment,paymentisprovidedfortheentireepisodeofcare,includingallservicesand
providers,andpaidtotheaccountableentitytosubsequentlypayeachproviderinturn.Thispayment
typicallyoccursaftertheepisodehasoccurredbutistermedprospective,asthepriceoftheepisodeis
establishedprospectivelybasedonwhatisdeemedtobeappropriatecarefortheepisode,andthe
savingsorlossesarenotsharedwiththepayertheyaresimplyafunctionofhowwelltheaccountable
entity(andtheproviderswithwhomitcoordinates)managetothepredeterminedprice.
InRetrospectiveReconciliation,individualprovidersareeachpaidonatypicalFFSbasis,andthenthere
isareconciliationbetweenthetargetepisodepriceandtheactualaverageepisodepriceafteraperiod
oftimeacrossalltheepisodesattributedtoaprovider.Aninitialreconciliationistypicallyconductedby
theendofthefirstquarterfollowinganepisodesend;afinalreconciliationistypicallyconductedwithin
sixmonthsoftheepisodescompletion.Forthisepisode,thistranslatestoAprilandJune.Basedona
specificformula,eithernegotiatedorestablishedbythepayer,theaccountableentitycanshareingains
and/orlosseswiththepayerand/orthepatient.Insomeinstances,gainsorlossesarealsoshared
amongprovidersintheepisodetoencouragecollaborationandcoordinationacrosssettings.These
typesofgainsharingarrangementsneedtobeconsideredwithintheparametersoffederallawsthat
mayimpacttheirdesign.SeeChapter6,OperationalConsiderations.
28
Figure6:RetrospectiveReconciliationvs.ProspectivePayment
Prospectivepaymentisgenerallyfelttoprovideastrongerstimulusforcareredesignthroughgreater
coordinationofcareacrossprovidersandcaredeliverysettings,butitisonlyanoptioninsome
circumstances.Thesemayincludewhentheaccountableentityisahealthsystemthatalready
integratestheclinicianandfacilitypayment.However,retrospectivereconciliationissimplerto
administer,asitrequiresfewerchangesfromcurrentpracticewheretheprevailingmodelisanopen,
nonintegratedsystem.Inaddition,retrospectivereconciliationismoreprevalentincurrentepisode
initiatives,asitdoesnotrequireproviderstodevelopthecapacitytopayclaims;allowsforbetter
trackingoftheresourcesusedintheepisode;andcanbebuiltonanexistingpaymentsystem.
Asapracticalmatter,itmaybemoredifficulttoimplementasingleprospectivepaymentwhenmultiple
providersinvolvedindeliveringthecaredonotalreadyhavemechanismsforadministeringpayment
amongthemselves,suchasisthecaseinintegratedsystems.Increaseduseofprospectivepaymentcan
acceleratedevelopmentofvarioussupportingmechanismstoaidinthisprocess.
Nevertheless,prospectivepaymenthasadvantagesinthatitisaclearbreakfromlegacyFFSpayment
andmayencouragegreatercoordinationandinnovationinepisodepayment.Forexample,ina
prospectivepaymentinitiative,itmaybemorefeasibletobeflexibleindeliveringotherwiseuncovered,
valueaddedservices,ortodeliverservicesthatwhilecoveredundertraditionalFFSare
underutilized,suchascoordinationservicesthatlinkpatientsrecoveringfromanelectivejoint
replacementwithcommunitysupports,transportation,andotherwraparoundservicesthatare
instrumentaltoensuringpatientsreceivethepostacutecareandrehabilitationtherapythattheyneed
toachieveapositiveoutcome.
Currently,mostepisodeofcarepaymentmodelsflowthrougharetrospectivereconciliationsystemdue
tothechallengesinherentinoperationalizingprospectivepaymentintheprevailingopen,non
integratedhealthcareenvironment.Asnotedabove,retrospectivereconciliationismoreprevalentin
currentepisodeinitiatives,asitdoesnotrequireproviderstodevelopthecapacitytopayclaims,keeps
bettertrackoftheresourcesusedintheepisode(usingadministrativeclaims),andcanbebuiltona
legacypaymentsystem.However,therecommendationistoconsiderprospectivepaymentwhere
possible.ProspectivepaymentisaclearbreakfromlegacyFFSpaymentandmayserveasafoundation
29
forgreaterinnovationinthequalityandcoordinatedcaredeliveryneededtomakeepisodepayment
successful.Further,ifaprospectivepaymentissharedamongproviders,itnegatestheincentivesofthe
FFSpaymentandcreatesimportantbuyinforcareredesign.
Prospectivepaymentmayworkbestinthecontextofahealthsystemthatalreadyintegrateshospital
andphysiciancare,asthemonetaryrelationshipamongthekeyprovidersisalreadyestablished.
However,evenunderprospectivepayment,itiscriticaltomaintainarecordofspecificservices
deliveredthatmaystillinvolvesomedegreeofFFSpayment.Thiswillallowforanalysesofbest
practicesthatleadtogreaterefficiencies,includinglowerlevelsofcomplicationsandfunctional
improvement.OnecautiononprospectivepaymentinaFFSMedicaidprogramisthattheremaybe
regulatorybarriersforoneproviderassigningpaymenttoanother.Legalcounselshouldbesoughtin
thisscenario.
8. EpisodePrice
provider/regionalutilizationhistory.Thepriceshould
1) acknowledgeachievableefficienciesalreadygainedbypreviousinitiatives;
2) reflectalevelthatpotentialproviderparticipantsseeasfeasibletoattain;and3)
includethecostofservicesthathelpachievethegoalsofepisodepayment.
Theepisodepriceiscritical.Itultimatelydeterminesthemonetaryrewardsorpenaltiesthataprovider
mayexperience.Itcanalsoplayaroleincreatingtheincentivesthatdeterminehowcareisdelivered
andwhetherthegoalsoftheepisodeareprioritized.Thereareseveralkeyaspectsthatinteractinthe
establishmentoftheepisodeprice,describedbelow.
LookBackPeriodforHistoricalData:Theappropriatelookbackperiodforhistoricaldatashouldbeset
accordingtotwovariables:numberofcasesthatoccurred,andthenumberofyears.Forelectivejoint
replacement,atwoyearperiodshouldyieldasufficientnumberofcasesonwhichtodeterminea
reasonableepisodeprice.Severityadjustment(describedmorefullybelow)canbeemployedtoexplain
muchofthevariationincostsofcarethatarewithinareasonabledistancefromtheaveragecostwithin
thattimeperiod.Itshouldbenotedthatthereisnowaytocompletelyeliminatemeasurementerrorin
thisprocess,butitcanbereducedbyusingalargeenoughsamplesize;thus,therelianceonnumberof
casesmaybeprioritizedoverthenumberoflookbackyears.
Onechallengewithdefiningalookbackperiodbyyearsand/ornumberofcasesisthatthenumberof
yearsandcaseswillvarydependingonwhethertheepisodeisbroadlydefined(i.e.includesawider
rangeofservices)ormorenarrowlydefined(i.e.includesasmallerrangeofservices).Toaddressthis
challenge,implementersmaythinkaboutthelookbackforhistoricaldatawithinthecontextofsettinga
targetmarginoferror.Thismargincanbedefinedasafactorofthenumberofcases,andtheunderlying
distributionandvariabilityofepisodecosts.Amorebroadlydefinedepisodewillrequiremorecasesin
ordertoachieveareasonablemarginoferror,whileamorenarrowlydefinedepisodewillbeabletofall
withinthatmarginbyusingfewercases.
BalancingRegionalandProviderSpecificData:Oncethelookbackperiodisdetermined,thecostdata
shouldreflectamixofproviderandregionalclaimsexperience.Thegoalofincludingregional,rather
30
thanmarketleveldataistoensurethatthereisenoughvariationinepisodecost.Thismixwillalso
ensurethattheestablishedepisodepricetakesintoconsiderationtheuniqueexperienceofthespecific
provider,andthatthegoalsaresetbasedonwhatisfeasibleintheregion.Riskadjustmentwillbe
neededduringthisprocesstoadjustfortheuniquecharacteristicsofthepopulationtheproviderserves.
Ifthepayerisanationalpayer,itmaybemoredifficulttoaddressspecificproviderissuesandwill
requireconsiderationoftheuseofnationalclaimsexperiencetoensureequityacrossregions.Over
time,asperformancebecomeslessvariable,itmaybeusefultolessentheproportionoftheepisode
lookbackperiodthatisbasedontheorganizationsspecificexperience.
RegionalCosts:Asnotedabove,usingregionallevelclaimsdataallowsthepayertotakeintoaccount
thecostsofmultipleproviderswithinaregion,reflectingthefactthatoneproviderscostsmaynotbe
fullyrepresentativeofwhatispossibleinthatregion.Italsoaddressesthevariabilitythatmayexistfora
providerwithalowvolumeofcases.However,theconcernwithusingregionalclaimsisthat,ifasa
whole,providersinthatregionhavealreadyachievedacertainlevelofefficiency,theymaybelessable
toachievefurthersavingsorwillachievelowersavings.Inessence,theseregions(ortheprovidersin
them)willarguethatanefficientregionwillbepunishedfortheirpreviousworktoachievethese
efficiencies.Ontheotherhand,iftheregion,onaverage,hasahigherperbundlecostthanother
regions(orspecificproviderswithintheregion),thepayermaynotachieveasgreatalevelofsavings
thaniftheepisodepricewastobesetatanationalorproviderspecificlevel.Insituationswherea
regionisnotlargeenoughtoreflectsufficientvariationacrossproviders,alargerregionmayneedtobe
defined.
ProviderCosts:Providerspecificcostsaretheactualcostsforthepreviouspatientsoftheprovidernow
responsibleforthepatientepisode.Forexample,ifahospitalisaccountable,theanalysiswouldbe
conductedusingthecurrentepisodedefinitionandapplyingittopatientswhoreceivedjoint
replacementsoverthelasttwoyears.Thechallengeisthatwhilethesecostsmaybeaccurateforagiven
institution,theymaybuildinalreadygainedefficienciesthatmakeitmoredifficultforanalready
efficientgroupofproviderstoachievesavingsorbuildininefficienciesthatlimitthesavingsforthe
payer.Anotherchallengeisinusingprovidercostsinawaythatdoesnotinhibittraditionallyhigh
performersfromcontinuingtostriveforexcellenceandimprovement.Onewaytoaddressthisistouse
multiprovidercostaverages,whichcancreateapayforperformancemodel,versusapayfor
improvementmodelwhichcanbenefitpoorperformersdisproportionately.
IncentivizeMoreEfficientLevelsofPractice:Inadditiontohistoricalproviderandregionleveldata,the
episodepriceshouldbebasedontheperformanceofthebetterperformersinaparticularmarket,such
thatallproviderscanseethattheepisodepriceandthequalitymetricperformancethresholdsare
feasibletoachieve.Ifaprovidersperformanceisalreadyatarelativelyefficientlevel,itwillneedtosee
somerewardforthatachievementatthesametimethatlowperformerswillhaveanincentiveto
improve.
Theepisodepricecanberevisedovertimetoensurecontinualimprovementbyboththemoreandless
efficientproviders.Inthisway,theepisodepriceautomaticallyintegratessavingsandsimultaneously
incentivizesacompressionofvariationincostandqualityacrossallproviders.Finally,theepisodeprice
shouldtakeintoaccountservicesthatarehistoricallyunderreimbursed,andthus,underused,butareof
highvaluetothepatient.Carecoordination,patientengagement,shareddecisionmaking,and
assessmentofpatientreportedpainandfunctionareexamplesofservicesthatcouldfallunderthis
category.
31
OtherFactorsImpactingEpisodePrice
Therearemanyotherfactorsthatshouldbeusedindevelopingtheepisodeprice,thoughtheabilityto
dosowilldependontheavailabilityofdataandanalytictools.Forfurtherdiscussiononthistopic,
pleasereadthepaperonFinancialBenchmarking,clickhere.
Factorsimpactingpriceinclude:
SocioEconomicStatusofthePatientPopulation:Thereareanumberofsocioeconomicfactorsthat
haveasignificantimpactonapatientshealthstatuspriortothejointreplacementprocedure,accessto
care,andpostprocedurerehabilitationandfollowupcare.Theseincludeincome,healthliteracy,living
status(livingalone,livinginacommunitywithoutfamilyorothersupportsnearby),availabilityof
transportation(bothingeneral,andtocaresettings),andothers.Certainsocioeconomicfactorsmay
alignwithaspecificpayercategory,whetheritbeMedicareorcommercialpayers.
Publicvs.PrivatePayers:Therearedifferencesbetweenpublicandprivatepayersthatshouldbe
acknowledgedandreflectedintheepisodepricing.Inadditiontothesocioeconomicstatusofthe
patientpopulation,asdescribedabove,thereisalsoadifferenceinhowoverallpricingisset.Forprivate
commercialpayers,pricingisanelementofnegotiation;inthepublicpayerrealm,pricesaresetbythe
publicpayer.Eitherway,thiswillimpactthelevelatwhichtheepisodepriceisset,aswillthemarketin
whichthepayeroperates.Mostprivatesectorpayerswillneedtonegotiatewithprovidersonthe
episodeprice,particularlyifparticipationisvoluntary.Iftheinitiativerequiresparticipation,itmaybe
easiertoestablishanepisodeprice,asisthecasefortheCJR.
TrustedEmpiricalData:Onechallengeistheabilityforpayersandproviderstounderstandthevariation
inthecostsoftheepisodeacrosstheirregion.Determiningtheappropriatepricerequiresempiricaldata
fromatrustedsource.Theavailabilityofthesedatatoidentifytheopportunitiesforefficienciesis
criticaltothesuccessoftheseinitiatives.
EpisodePaymentFlow:Theepisodepricecanbesetretrospectivelyinanepisodemodelforwhich
retrospectivereconciliationistheselectedpaymentflow.Similarly,thepricecanbesetprospectivelyin
amodeldesignedaroundprospectivepayment.Thus,settingtheepisodepriceandthepaymentflow
shouldbepartofanintegratedprocess.
PatientandFamilyDefinitionsofValue:Informationonthetypesofservicesthataremostvaluedby
patientsandtheirfamiliesshouldbeconsideredindeterminingtheepisodeprice.Thisinformation
wouldnottypicallybecapturedviahistoricaldata,butratherviaengagementbetweenprovidersand
theirpatients,aswellasbetweenpurchasersandtheiremployees.
MultipleWaystoBuildinSavingsforEJREpisodes:Onecommercialbundledpaymentmodel,the
PROMETHEUSpaymentmodel,buildsinanassumptionofalowerlevelofcostsforcomplications
andreadmissionsandadjuststheepisodepriceaccordingly.Ontheotherhand,theoriginal
GeisingermodelsProvenCareTMwarrantystrategybuiltinanassumed50%decreasein
complicationsintoitswarrantyprice.Meanwhile,otherpayersbuildinsavings,regardlessof
whetherthecalculationisbasedonproviderorregionspecificestimatesordecreasesin
readmissionsorcomplications.CMSbuiltinasetdiscountfactorofthreepercentandallowedfor
theepisodepricefortheCJRtobesetusingamixofhospitalspecificandregionaldata,shiftingtoa
moreregionalapproachoverafiveyearperiod.Theprovidersperformanceonkeyqualitymetrics
canbeutilizedtolowerthediscountfactorifitsperformanceishighenough.
32
9. TypeandLevelofRisk
Transitionperiodsandriskmitigationstrategiesshouldbe
usedtoencouragebroadproviderparticipationandsupportinclusion
ofasbroadapatientpopulationaspossible.
Thegoalwhensettinganepisodepriceshouldbeto
incorporatebothupsiderewardanddownsiderisk.Absent
downsiderisk(wheretheactualcostsofcareexceedthetarget
episodeprice),theaccountableentityandotherproviders
involvedhavelessincentivetomakethenecessarychangesin
howcareisdeliveredtocreateefficienciesandimprove
patientoutcomes.Further,increasesinthecostofcarefrom
yeartoyearoftennegatethebenefitsofupsidesharingof
savings,particularlywhentheepisodepriceisbasedon
historicdata.However,takingondownsideriskmaybe
difficultforsmallerproviders,includingmanyphysician
practices,thatarealsothemostabletomakethenecessary
changesinajointreplacementepisodeofcare.
Toaddresstheseconcerns,payerscanutilizestrategiestolimit
thatriskortotransition(phasein)thedownsideriskovertime.
Thisisparticularlyimportantiftheinitiativeisvoluntaryand
participationwouldbelimitedabsenttheoptionforupside
rewardonly.Decisionsabouttype,level,andtimingofupside
rewardanddownsideriskillustratetensionsbetweenpayers
andproviders:certainriskarrangementsmaybemore
acceptabletopayersthantoproviders,andviceversa.
Consequently,intheprivatemarket,thesefactorsbecome
partoftheongoingnegotiationsamongnetworkparticipants
andpayers.Regardlessofthemechanismusedtolimitrisk,itis
criticalthatthemethodologyfordevelopingthatmechanism
betransparent,aswellasmodifiable,dependingonthetiming
oftheprocedure.
SafetyNetProvidersandRisk
Aprimarygoalindesigningany
alternativepaymentmodel
arrangementisguardingagainst
unintendedconsequences.Inepisode
paymentforelectivejoint
replacement,theunintended
consequencethatconcernsall
providersbutperhapssafetynet
providersmostofallisthepotential
fordecreasedaccesstocarefor
patientswithpoorhealthstatus,which
putsthematincreasedriskforpoor
outcomes.Thismaybecorrelatedwith
lowersocioeconomicstatusifthe
providerfeelsthatitwillnotbe
possibletoprovidethefullcontinuum
ofcareandachievepositiveoutcomes
withintheepisodeprice.Safetynet
providersinparticularmayneedtime
todevelopadequatereportingand
staffinginfrastructure;andbuild
relationshipsacrosshistoricallysiloed
organizationsinordertofeelprepared
totakeontheriskinanepisode
paymentmodel.
MechanismsforLimitingRisk:Thelevelatwhichthoserisk
limitsaresetisacriticaldesignelement.Thereareanumberofissuestoconsider,suchaswhetherthe
accountableentitywillberequiredtopaythefulldifferencebacktothepayerbetweentheestablished
episodepriceandtheactualepisodecostsorwhetherlimitswillbeestablished.Limitsareespecially
importantconsideringthataproviderisoftenalsoaccountableforcareprovidedbyseveralother
providersacrosstheepisode.WhattheaccountableentityispaidthroughFFSpaymentistypicallynot
sufficientforthemtopaybackapayerifthecostsovertheepisodepriceareduetohigherthan
33
expectedutilizationofotherprovidersservicesacrosstheepisode.Therefore,followingarestrategies
usedbyvariousinitiativestolimitriskinanepisodepayment:
RiskAdjustment:Riskadjustingtheepisodeprice,basedontheseveritywithinthepopulationinthe
electivejointreplacementbundle,isoneriskmitigationstrategy.Thereareavarietyofapproachesto
capturingpatientcharacteristics,diseasestatus,andotherparametersthatpredictepisode
expenditures.Forexample,theHealthCareIncentivesImprovementInstitutes(HCI3)evidencebased
caserates(HealthCareIncentivesImprovementInstitute,[n.d.])createavarietyofpatientspecific
episodesthatrecalibratebasedonvariouspatientspecificseverityfactors.Anotherexample,the
MedicarePaymentAdvisoryCommission,initsanalysisofbundling,utilizedvariousriskadjustment
tools,6includingmarkersoffunctionalstatusandcomorbidities,toadjusttheunderlyingepisodefor
theiranalysis.Forfurtherdiscussiononthistopic,pleasereadthepaperonFinancialBenchmarking,
clickhere.
StopLossCaps,RiskCorridors,andCapitalRequirements:Otheroptionsforlimitingthelevelofrisk
include:Limitsatboththeindividualandaggregatelevelsthatcouldbeincludedasstoplossinsurance;
riskcorridorsthatlimitexposureandgains(CJRincludesarampupoftheexposurefromanupperlimit
of5%ofthetargetpriceto20%ofthetargetpricebyyearfive(5)ofthemodel);andsomelevelof
capitalrequirementstocoverthelosses.Anotherconsiderationmaybetolimittheriskforanyentityto
someportionoftheoverallcostsoftheepisodebasedontheaccountableentitysroleintheepisode.
InteractionBetweenRiskMitigationStrategies:Illustratingtheinteractionbetweenriskadjusting
theepisodepriceandotherriskmitigationstrategies,foroneexistingjointreplacementepisode
paymentinitiative,apayerdecidednottoriskadjusttheprice,but,instead,establishedarisk
corridorthatcappedexposureat115%oftheepisodeprice.Thismethodlimitsproviderexposure,
avoidsthecomplexityofriskadjusting,andprovidesasettarget.
http://www.medpac.gov/documents/contractorreports/sept13_episodebundle_contractor.pdf?sfvrsn=0
34
10. QualityMetrics
Prioritizeuseofmetricsthatcapturethegoalsoftheepisode,includingoutcome
metrics,particularlypatientreportedoutcomeandfunctionalstatusmeasures;use
qualityscorecardstotrackperformanceonqualityandinformdecisionsrelatedto
payment;andusequalityinformationandothersupportstocommunicatewith,and
engagepatientsandotherstakeholders.
Episodepaymentencouragesbettercommunicationandcoordinationofcareacrossproviders.Thisputs
thepatientatthecenterofthecareacrosssettingsandhelpsachievethegoalofimprovingquality,
providingpositivepatientexperiencesandpatientoutcomes,anddoingitallwithinadefinedpriceto
reduceunnecessarycare.
Qualitymeasurementiscriticaltoachievingallofthesegoals.Qualitymeasuresmaybeusedtohold
providersaccountableforthequalityofcarebeinggiven,thelevelofresourceuse,andapatients
experiencewiththecare.Accountabilityrequirestheuseofprocessmeasuresaswellasoutcome
measures(clinicalandpatientreported).Italsorequiresmeasuresthatreflectcareacrosssettingsas
wellaswithinindividualprovidersettings.Patientsneedproviderspecificperformancescorestoassist
themwithselectingindividualproviders,andprovidersneedtoknowthatpatientsareexperiencing
positiveoutcomesacrossallsettingswithintheepisode.
TheCEPWorkGrouprecommendsusingPatientReportedOutcomeMeasures(PROMs)andmeasures
offunctionalstatuspreandpostprocedureforaccountabilitypurposes,andadditionalclinicaloutcome
measuresshouldbeconsideredforbothaccountabilityandpayment.
Inselectingthemetricsforanepisodepaymentmodel,itisimportanttorecognizethepreferencefor
alignmentofmeasuresacrossprograms,useofnationallyendorsedmeasures,andalimited,tightsetof
measureswithalowburdenofcollection.TheCEPWorkGroupsupportstheseprincipleswheneverthey
canbemetwithmeasuresthatincentpriorityopportunitiesforimprovingelectivejointreplacement
care.Ameasurethatmeetsthesecriteriawithoutthepotentialforclearbenefitsforpatientswouldnot
befitforthispurposeandisnotrecommended.TheWorkGroupisnotincludingrecommendationsfor
specificqualitymetricsatthistime.
Measuringandtrackingperformanceonqualityarecriticalforthesuccessofclinicalepisodepayment.
Measuresofqualitymustbeidentified,andthemannerinwhichinformationontheperformanceon
qualitywillbeusedmustbedefined.Todosorequires:
Selectingclinicalandpatientreportedoutcomemeasures,andfunctionalstatusmeasurestotrack
providerperformanceforservicesdeliveredwithintheepisodetoensurethatthefiscalsavings
incentivesdonotincentivizelowerqualitycarebutimprovequality;
Creatingaqualityscorecardwithperformancethresholdsorbenchmarksagainstwhich
performanceisassessedandusedtoinformpayment;and
Usingqualitymetricsforcommunicatinginformationtoconsumersandpatientsinawaythatis
meaningfulandsupportspatientengagement.
35
PrioritizeUseofOutcomeMeasures(ClinicalandPatientReported),andFunctionalStatusMeasures
Definingqualitymetricsforepisodescanbechallenging.Manyqualitymeasurementmetricsare
designedformeasuringthequalityofcareinasinglesettingofcareandnotforobservingqualityover
multiplesettings.Forexample,withhipandkneereplacement,complicationsinahospitaldonot
measurewhatmayhavehappenedinapostacutesettingwheretheimprovementinfunctioningisa
primarygoal.Anotherissueisthatsomemetricsweredesignedforbroadertopics,suchaspatient
experiencesurveysofahospitalexperience,andmaynotbedesignedtocapturekeyattributesofthe
patientexperiencespecifictojointreplacementepisodesthatoccurovertimeandovermultiple
settingsandproviders.
Therearemetricsavailabletodayformeasuringthequalityofthesurgery,aspectsofthepatient
experience,andtoassesspainandfunctioningpreandpostprocedure(asdescribedin
Recommendation1,EpisodeDefinition).Patientexperiencesurveymeasuresshouldincludequestions
aboutpatientsexperiencewithpainandpainmanagement;functionalstatusassessmentsshould
includemeasuresofambulatoryfunction,andshouldbeconductedimmediatelypostprocedureandat
sixmonthintervalsthroughthedurationofthe12monthqualitymeasurementcycle.
Thereisnotastandardnumberofmeasuresthatshouldormustbeusedtosupportelectivejoint
replacementepisodepayment.Theprevailingwisdomistoseektouselessmeasures,butmakethose
measuresmorepowerfulintermsofhowmuchinformationtheyimpartaboutthecaredelivered.
Examplesincludestandardizedandconsensusbasedmeasuresofcomplicationratesandhospital
readmissions,whichcanprovideinformationabouttherelationshipbetweenreducingcostsofcareand
theeffectsonquality.Standardizedmeasuresofcomplicationsandreadmissionsarealignedwiththe
goalsforlowercostsasthelowertheratesofcomplicationsandreadmissions,thelowerthecostsof
theepisode.
Finally,alloutcomemeasuresusedtodeterminepaymentorreportedtopatientsmustbeaccurately
riskadjustedtoaccountforarangeofcomplexityinthepatientmix.Inconsideringwhichmeasuresto
implement,oneresourceistheOrthopedicMeasuresCoreSet,Version1.0(Table5),developedbythe
CoreQualityMeasuresCollaborative(CQMC)isnotmeanttobeanexhaustivelistofwhatisavailable.
Rather,itisacoresetofmeasuresdevelopedbyamultistakeholdereffortalignedatimplementation
byprivateandpublicpayers.
36
Table5:CQMCConsensusCoreSet:OrthopedicMeasures,Version1.0
ConsensusCoreSet:
OrthopedicMeasures,Version1.07
Hospitallevelriskstandardizedcomplicationrate(RSCR)followingelectiveprimarytotalhip
arthroplasty(THA)and/ortotalkneearthroplasty(TKA)
Hospitallevel30day,allcauseriskstandardizedreadmissionrate(RSRR)followingelective
primaryTHA
SurgicalCareConsumerAssessmentofHealthcareProvidersandSystems(CAHPS):
Informationtohelpyouprepareforsurgery;
Howwellsurgeoncommunicateswithpatientsbeforesurgery;
Surgeonsattentivenessondayofsurgery;
Informationtohelpyourecoverfromsurgery;
Howwellsurgeoncommunicateswithpatientsaftersurgery;
Helpful,courteous,andrespectfulstaffatsurgeonsoffice;and
Ratingofsurgeon.
Source:CoreQualityMeasuresCollaborative;https://www.cms.gov/Medicare/QualityInitiativesPatient
AssessmentInstruments/QualityMeasures/CoreMeasures.html.
PatientExperienceofCare:Giventhecentralroleofcarecoordinationtoepisodepayment,payersuse
patientexperiencesurveystoassesswhetherpatientproviderinteractionsaresupportingthegoalsof
thepaymentinitiative.Forexample,theCJRinitiativeplanstoutilizetheHospitalConsumerAssessment
ofHealthcareProvidersandSystems(HCAHPS)(CentersforMedicare&MedicaidServices,2014)
patientexperiencesurveyforthispurpose.SurgicalCAHPS(SCAHPS),whichisdesignedforsurgical
episodes,ismorespecifictothepresentcontextandisincludedintheCQMCsorthopediccoreset
(CentersforMedicare&MedicaidServices,2016).
PROMs:Patientreportedoutcomes,particularlythoserelatedtofunctioningandpain,arecriticalin
electivejointreplacementepisodesbecausethesearethetwokeyproblemstheproceduresare
designedtosolve.Functioningandpainshouldbemeasuredbothpreandpostprocedure.Giventhata
patientassessmentshouldbedoneasarequirementforapatienttobeincludedinanepisodepayment
initiative,thesametoolshouldbeusedpriortotheprocedureandatdefinedintervalsafterthe
proceduretoensurestandardizationandmeasureimprovement.Severalassessmentinstrumentsare
utilizedinpostacutesettingsthatincludethesetypesofitemsandcanbeevaluatedtodeterminetheir
utilityinjointreplacementepisodepayment.Atthistime,theCEPWorkGrouprecommendsthata
patientschangeinfunctionalstatusshouldnotaffectpayment,ratherpaymentshouldbebasedonthe
useofthesepreandpostprocedureassessmenttool).
7
TheCQMCiscurrentlyoverseeingaworkgrouponPatientReportedOutcomeandPatientExperiencemeasures,
whichisreviewingthefollowingmeasuresrelatedtohipandkneereplacement.
37
Aspartofthiswork,theCQMCisreviewingNQFmeasures0422(Functionalstatus:kneeimpairments,
usingFocusonTherapeuticOutcomeskneePROM)and0423(Functionalstatus:hipimpairments,using
FocusonTherapeuticOutcomeshipPROM).TheCQMCworkgroupisalsoreviewingNQF2653:Average
changeinfunctionalstatusfollowingtotalkneereplacementsurgery,usingtheOxfordKneeScore.
QualityScorecards
Mostepisodepaymentinitiativesuseaqualityscorecardwithdefinedthresholdsthataprovidermust
meetorexceedinordertoreceiveeitherthefullreimbursementforanepisodeorthefullshared
savingspossible.However,decisionsonwherethosethresholdsaresetorhowtheyareusedshouldbe
uptothepayerandprovidertonegotiate(thisappliestothecommercialmarket;seebelowfor
comparisonwiththepublicsector).Someinitiativesvarythelevelofsharedsavingsbasedon
performanceonthemetrics,whileothersalsouseminimumperformancelevelsasathresholdfor
receivinganyportionofthesavings.Issuesthatmustbeconsideredwhendevelopingqualityscorecard
thresholdsinclude:
CollectingSufficientData:Itisimportanttocollectsufficientdatatoinformthethresholdlevels.Thisis
ofparticularconcernwhenitcomestousingmeasuressuchasafunctionalstatustool.Sinceuseof
thesetoolsisrelativelyrecent,theremaynotbeenoughinformationonwherethethresholdshouldbe
set.
DrivingQualityandPatientSafetyImprovement:Whileintheinitialyearsofepisodepaymentthe
thresholdsmaybesettoallowforthegreatestopportunityforsharingsavings,thegoalshouldbetoset
thresholdsatapointthatincentivizesinnovationincareimprovementovertime,whichultimatelywill
drivequalityandpatientsafetyimprovement.
LackofAlignment:Theremaynotbealignmentbetweenpublicsectorandcommercialsectorepisode
paymentmodelswhenitcomestoaqualityscorecarddesign.Commercialpayershaveadifferentability
tonegotiatepaymentrelatedtoperformancewiththeirprovidersthanCMSorthestates.Inaddition,
thethresholdlevelsmayvarygiventhedifferenceintheirpopulations,whichmaymakealignment
acrosssectorschallenging.However,effortssuchastheCQMC,whichrepresentscollaborationamong
CMS,AHIP,andtheNationalQualityForum,areseekingtoaddressthisissue.
Notethatqualitymeasuresareneededforuseinpaymentandforconsumerinformation;however,one
concernisthatprovidersmaynotbeaswillingtotakeonpatientsatriskforpooroutcomesifthese
typesofoutcomemeasuresareusedintandemwithpayment.Anotherconcerniswhetherstakeholders
haveconfidenceinthequalityofthemetricitself.
QualityInformationtoCommunicateandEngagewithPatients
Inadditiontousinginformationonqualitytodeterminepayment,itisimportantforotherstakeholders
tohaveaccesstodataonquality.Tobeinformedontheoutcomesacrosssettings,patientsneedquality
data(ideallypriortomakingthejointreplacementproceduredecision)aboutthephysicians,surgeons,
hospital,andpostacutecareproviders,particularlyiftheyhaveachoiceofproviderteamsand/or
settingsinwhichtoreceivecare.Currently,therearegapsintheavailabilityofsuchdata,aswellasa
lackofresearchontheextenttowhichconsumers(orpayers)findsuchinformationuseful.
Tomakeoptimaluseofavailablecomparativequalityinformation,consumersshouldhaveaccessto
personnelwhocanhelpthemidentifyandinterpretinformationrelevanttotheircircumstances,and
whoarenotundulyconflicted,allowingthemtoprovidehelpful,disinterestedadviceand
recommendationstothepatient.
38
Employersandpurchasersneedtomakedataonqualityavailabletoemployeestosupporttheiruseof
providersthatofferbundledpaymentforjointreplacement.Specifically,employeesneedtounderstand
thebundleandwhattheirroleisinreceivinghighqualitycare.
Primarycareprovidershopingtoenterintobundledpaymentcontractswillwantdataaboutspecialty
physicianqualityperformanceinordertodeterminewhichbundledarrangementswouldbemost
beneficialtotheirpatientpopulation.
Finally,episodepaymentdesignmustbuildinthecapacitytocollect,analyze,andprovidedataand
supportpatientsinidentifyingandinterpretingthisinformation.Itisimportant,therefore,toestablish
crosscuttingeffortstodefinemetricsandsystemsfordatacollectionandanalysis.Butitisasignificant
burdenforeachinitiativetodefineitsownmetrics,collectionsystem,andscorecard.Consequently,one
placetolookwouldbetheCQMCprocessfordefiningmetricsandtheuseofexistingreporting
mechanisms,suchasHospitalCompare,PhysicianCompare,NursingHomeCompare,andHomeHealth
Compare,whichproviderelevantinformationonthequalityoftheircareonhipandkneereplacements
andrehabilitativeservices.Clinicalregistriesalsohaveexperiencewithcollectingandanalyzingrichdata
oncomplicationsandotheroutcomesforjointreplacement.Broadereffortsareneededtobuildthe
necessaryinfrastructureformeaningfuldevelopmentand useofqualityperformance information,and
buildingthesesystemsisoneofthekeychallengesdiscussedintheOperational Considerationssection
ofthisWhitePaper.
39
Insertcoverpage
40
Chapter4:MaternityCare
Background
Pregnancyandchildbirtharepivotaleventsinawomanslife,framedbyboththeoverallcare
experienceandtheactualbirthevent.Duringpregnancy,womenareconcernedwithmanythings,
includingthehealthydevelopmentofthebaby,thelaborandbirthexperience,andhowtheywilltake
careofthemselvesandtheirnewbornspostpartum.Interactionswiththehealthcaresystemduringthis
timecreateopportunitiestoaddressandallaytheseconcernsbylayingastrongfoundationforthe
ongoinghealthofthewoman,herbaby,andherfamilyasawhole.Oftenprenatalcare,laborandbirth,
andpostpartumcareareviewedanddeliveredasthreedistinctperiods.However,byviewingthemas
threephaseswithinoneepisode,thereisapotentialforincentivizingthetypesofinteractionsandcare
deliverythatsupportpositiveoutcomes.
Positiveoutcomesformaternitycarecanbedefinedandachievedinavarietyofways,suchas:
Agreaterpercentageofappropriatevaginalbirths;
Agreaterpercentageoffulltermbabiesbornathealthyweights;
Strongrecoveriesforwomen;and
Healthystartsforthebabies.
Thoughtfulepisodepaymentseekstoachievetheseoutcomesataloweroverallcosttothesystem,and
atalowercosttowomenandfamilies.TheWorkGroupsrecommendationsprovideguidanceonhow
toachievethisgoalwithoutbecomingoverlyprescriptiveabouttheexactmechanismsfordoingso.
Inmaternitycaretoday,thereareavarietyofpaymentmechanisms.Paymentoftenincludesaglobal
feeforprofessionalservicesforprenatalcare,andthemanagementofthelaborandbirth.Itwill
sometimesalsoincludepostpartumcare.Facilityfeesfortheactualbirtharetypicallypaidseparately,
withhigherfeesintheeventofabirthbycesareansection.Therearealsoseparatefacilityand
professionalfeesforthenewborn.Thesedifferentpaymentmechanismsareoftenassociatedwith
overuseofhighcostinterventionsandunderuseoflowcostinterventions,whichleadstolessthan
desirableoutcomesforwomenandtheirbabies,despitethefactthatthematernitypopulationis
generallyhealthy.ItisalsoimportanttonotethatmaternalmortalityintheUnitedStateshasrisenover
thepast30years(CentersforDiseaseControlandPrevention,2016).Byprovidingincentivesforthe
provisionofhighervaluepractices,andforcarecoordinationacrossthecontinuumofservicesand
providers,episodepaymentcanpotentiallyhaveasignificantimpactonboththeshortandlongterm
healthofawomanandherbaby,andonthehealthofAmericansociety.
ChildbirthisthemostcommonreasonforhospitalizationintheUnitedStates.In2009,combined
maternalandnewbornstaysrepresented23%ofallhospitalstays(AgencyforHealthcareResearchand
Quality,2011).AccordingtoHealthcareCostandUtilizationProject(HCUP)data,whilechargesbilledby
hospitalsrepresentasignificantoverestimateofactualpayment,suchchargestotaled$127billionin
2013(actualpaymentsareroughlyhalfofbilledcharges).Thesechargesdonotincludeprofessionalfees
orothersettingsofcareacrosstheepisode.Inaddition,hospitalbilledchargesincreasedmorethan
90%between2003and2013(AgencyforHealthcareResearchandQuality,2003;AgencyforHealthcare
ResearchandQuality,2013).
41
AstudybyTruvenAnalyticsshowsthecostofbirthvariessignificantlybypayer,typeofbirth(vaginalor
cesareansection),andsettingwherethebirthoccurs(seeTable6).In2013,theaveragetotalmaternal
newbornpaymentsforcesareanbirths,includingallfacilityandproviderfeesforprenatal,laborand
delivery,andpostpartum/newborncare,was$27,866foracommercialpayerand$13,590forMedicaid.
Forbothpayertypes,totalpaymentsforcesareanbirthswereroughly50%higherthanforvaginal
births.Oneofthereasonsthatcesareanbirthcostsmoreisthatthereare50%higherneonatalintensive
careunit(NICU)paymentsassociatedwiththesesurgeries,comparedtothepercentageofvaginalbirths
requiringNICUstays.Further,thefactthatwomenwhoexperienceacesareanonceoftenhaverepeat
additionalcesareansaddingtosystemcosts.
Table6:CostsandDisparitiesinMaternityCare
Volume(HCUP2013)*
Medicare,Other,or
UninsuredAccounted
fortheRemainder
PaymentVariationby
PayerandTypeof
Birth(Truven,2010)
CommercialMarket
2,012,584births(48.99%)
Medicaid
1,811,759births(44.10%)
Vaginal:$18,329
Cesarean:$27,866
Vaginal:$9,131
Cesarean:$13,590
Significant
Opportunitiesfor
ImprovedOutcomes
Reducecesareanrates:Currentaverageofcesareanis32.2%,up60%
fromthemostrecentlowof20.7%in1996(Osterman&Martin,
2013).WHOdatafindthatcesareanrateshigherthan10%arenot
associatedwithfurtherreductionsininfantormaternalmortality
(WorldHealthOrganization,2015).
Reducepretermrates:9.57%ofbirthsarepreterm.TheAmerican
CollegeofObstetriciansandGynecologists(ACOG)recommendsno
earlybirthsunlessmedicallyindicated(Hamiltonetal.,2015).
Increaseinbirthsoccurringinthehighestvaluesetting:Vaginalbirths
are50%lesscostlyinbirthcentersthaninhospitals(Hamiltonetal.,
2015).
Reduceinfantmortalityrates:InfantmortalityishigherintheUnited
Statesthanin38othercountries(WorldHealthOrganization,2014).
ReducematernalmortalityrateintheUnitedStates,whichhas
doubledsince1987(WorldHealthOrganization,2014).
Reduceracial/ethnicdisparities:Theprevalenceofpretermbirths
fornonHispanicwhiteis8.91%,nonHispanicblackis13.23%,and
Hispanicsis9.03%,withadditionalsignificantdisparitiesininfant
mortalityandlowbirthweightbabies(Matthews&MacDorman,
2013).
Thesettinginwhichawomangivesbirthalsoaffectsthecost,aswellasthetypeofdelivery.The
averagenationalcesareanrateintheUnitedStatesiscurrently32.2%(Matthews&MacDorman,2013;
WorldHealthOrganization,2015).Justaswithothersurgicalprocedures,thereissignificant,non
clinicallysupportedvariationincesareanratesacrosshospitals.Evenhospitalsinthesamecityshow
42
widevariation.Forexample,JerseyCityMedicalCenter,nearNewark,N.J.,reporteda35%cesarean
sectionrateforlowriskwomen,comparedtoa19%rateatTrinitasRegionalMedicalCenterinnearby
Elizabeth,N.J.(Haelle,2016).InCalifornia,ratesvariedfrom18%inonehospitaltomorethan50%in
another,accordingtoarecentstudy(Mainetal.,2011).HealthyPeople2020callsforareductionin
nationwidecesareanratesforlowriskwomento23.9%by2020.
Forwomenwhochooseamidwifeand/orabirthcenterfortheirprimarycareproviderandbirth
setting,respectively,thecostsaresignificantlylessthaninahospital.Ofcourse,partofthisisduetothe
factthatbirthcentersdonotprovidecesareansectionprocedures.Thereareoccasionswhenawoman
choosesamidwifetomanageprenatalcareandabirthcenterforlaborandbirth,butultimatelydelivers
inahospitalduetocomplications.Thecostsinthisscenarioarestilllowerforvaginalbirthifamidwife
managedtheprenatalcareandsubsequentlymanagesthehospitalbirth(Howelletal.,2014).Theuse
ofcommunitybasedsettings,suchasbirthcentersandhomebirthsisgrowing.In2014,18,219babies
wereborninbirthcenterswhileanother38,094babieswerebornathome(MacDorman,Matthews,&
Declercq,2014).However,thevastmajorityofbirthsintheU.S.98.6%stilltakeplaceinahospital
setting(Hamiltonetal.,2015).
Thesedatademonstratethattoooftentheresourcesspentonmaternitycareservicesarenotleadingto
thehighestvaluebirthcare.ThefactthattheUnitedStateshasahigherrateofinfantmortalitythan38
othercountriesandalowersuccessfulbreastfeedingratethan98othercountriesreflectsthis(World
Healthorganization,2014).Itisalsoreflectedinthe9.57%pretermbirthratein2014.Finally,thereare
significantracialandethnicdisparitiesinbirthoutcomes.NonHispanicblackbabiesareatmorethan
twicetheriskofdyingatbirthcomparedtononHispanicwhitebabies(CentersforDiseaseControland
Prevention&HealthResourcesandServicesAdministration,2012).
Thegoodnewsisthatevidencebasedcarepracticescandeliverhigherqualitycareatalowercost.For
themajorityoflowriskbirths,lowerresourceintensivebirthscorrelatewithpositiveoutcomes.Thereis
nosingledefinitionoflowriskbirth.However,HealthyPeople2020usedthisdefinitiontodefinelow
riskforcesareansections:Fullterm,singleton,andheadfirstpresentation.DatafromtheNational
CenterforHealthStatisticsshowthatasmanyas80%ofbirthsmeetthisdefinition.Ifthepercentageof
safelyachievablevaginalbirthsfortheselowerriskpregnanciesweretoincrease,resultinginadecrease
incesareans,overallbirthcostswoulddecrease.Outcomesshouldimproveaswellbecausevaginal
birthshavefewercomplications.Further,withadecreaseintherateofearlyelectiveandpreterm
births,fewerbabieswouldneedhighcostNICUcare,andbabieswouldhavehighersurvivalratesanda
healthierstarttolife.Atthesametime,thoseatelevatedriskfromsuchconditionsasgestational
diabetes,obesity,ortwinpregnancycanbenefitfrompersonalizedcarefosteringhealthyoutcomes.
Althoughtherelationshipbetweenqualityofcareandbetterhealthoutcomesisrecognizedbythefield,
thisrelationshipisnotalwaysreflectedinthecurrentU.S.paymentsystem,whichischaracterizedbya
tendencytoincentivizehighercostandlowerqualitycare.Inthematernitycarecontext,vaginalbirths
costless,havefewercomplications,andinvolveshorterstays,thusprovidinglessreimbursementto
hospitals;buttheyalsorequirepatienceandoftenseveralhoursofhardworkbythewomen,aswellas
supportfromthecareteam.Incontrast,cesareansaresometimesconsideredmoreconvenientby
women,practitioners,andfacilitiesbecauseoftheshorterdurationoflaborandtheabilitytoschedule
inadvance(TruvenHealthAnalytics,2013).Inpart,therateofcesareanshasincreased60%fromthe
mostrecentlowof20.7%in1996becauseofthis(AgencyforHealthcareResearchandQuality,2011).
Thisisdespitethefactthattheyareconsideredriskierforboththemotherandbaby.ACOGandthe
SocietyforMaternalFetalMedicinehavebothstatedthatthisincreasehasnotbeenaccompaniedby
43
discernablegainsinmaternalornewbornhealth(AmericanCollegeofObstetriciansandGynecologists,
2014).
RoleofEpisodePaymentinMaternityCare
Thegoalofusingclinicalepisodepaymentsistoimprovethevalueofmaternitycarebyimprovingthe
outcomesandexperienceofcareforthewomanandherbabywhilereducingcosts.Althoughthe
paymentincentivesinepisodepaymentprovidesignificantsupportforthisgoal,thedesignand
implementationoftheepisodescarepathway(s)anddeliverymodel(s)arealsocriticalforexample,
ratesofcesareanbirthsorearlyelectiveinductionscouldbeimpactedbychangingprotocolswithina
hospital.TheCEPWorkGroupbelievesthatthegoalofepisodepaymentshouldgobeyondlowering
costs,andthatitshouldbedesignedsuchthatitsupportsamorepatientcenteredapproachtocare.
Specificgoalsofmaternityepisodepaymentinclude:
Increasingthepercentageofvaginalbirthsanddecreasingunnecessarycesareanbirths;
Increasingthepercentageofbirthsthatarefulltermanddecreasingpretermandearlyelective
births;
Decreasingcomplicationsandmortality,includingreadmissionsandneonatalintensivecareunit
(NICU)use;
Providingsupportforchildbearingwomenandtheirfamiliesinmakingcriticaldecisionsregarding
theprenatal,laborandbirth,andpostpartumphasesofmaternitycareandrespectingthose
choices;
Increasingthelevelofcoordinationacrossprovidersandsettingsofmaternitycare;and
Consistentlyprovidingawomanandfamilycenteredexperience.
Careimprovementsmustoccuracrossthecontinuumofprenatal,laborandbirth,andpostpartumcare
inordertosupportamorepatientcenteredapproachtocare.Episodepaymentcanaddresstheneed
forappropriate,highquality,prenatalandpostpartumcare.Testingforpotentialproblems(suchas
gestationaldiabetesorbirthdefects);monitoringthegrowthandhealthofthegrowingfetusandthe
woman;providingeducationtothewomanonwhattoexpectduringandafterbirth;andsupportingher
inmakingdecisionsaboutherpreferencesforinterventions,settings,andprovidertypescanallleadto
amoreengagedandhealthiermother.Postpartumcarethatsupportsthenewmotherinbreastfeeding,
babycare,contraceptivecare,mentalhealth,andselfrecoverycanhavealifelongimpactonthehealth
ofboththewomanandherbaby.Yettheseandotherhighvalueservicesarenotalwayseffectively
providedbecausethebulkofpaymentisfocusedonhospitalbasedlabor/deliveryservices.Therefore,
thegoalofepisodepaymentdesigninthisrealmisbothtoincentivizethedeliveryofthefullcontinuum
ofservicesbyholdingprovidersaccountablefortheirqualityandcoordination,andtodecreasecosts
whileimprovingthevalueofmaternitycareoverall.
Fortunately,Medicaid(whichpaysforapproximately45%ofbirthsannually),commercialpayers,and
largepurchasershavebeguntodevelopepisodepaymentinitiativesformaternitycareinrecognitionof
thewaysinwhichepisodepaymentcandrivehigherquality,lowercostcare(KaiserFamilyFoundation,
n.d.).
44
Therearethreegeneraltypesofmodelsinthemarkettodaythatbundleallorsomeoftheservicesfor
maternitycareintoanepisodepayment.SeeAppendixDforatablesummarizingvariousinitiatives.
Examplesofeachmodelarebelow.
ComprehensiveBundle:Severalinitiatives,ledbybothMedicaidandcommercialpayers,definethe
episodeastheprenatal,laborandbirth,andpostpartumtimeframeandincludecareforthewoman
andsometimesthenewborn.Thisstrategyacknowledgestheimportanceofsupportthroughoutthe
entirematernitycareexperiencetoensurethebestoutcomesforthewomanandherbaby.Itis
agnosticastoboththebirthsiteandwhomanagesthebirth,andastowhetherthebirthisvaginalora
cesarean,butitistypicallypricedassumingahospitalbirth.
ComprehensiveBirthCenter/MidwifeBundle:Thisproviderdrivenepisodemodelincludesthefull
continuumofservices,muchlikethecomprehensivebundles,butispricedbasedonmidwife
management,andthusreflectsthecostofabirthcenterbirth.Inthismodel,ifawomanisreferredtoa
hospital,thenthehospitalispaidaseparatefee;thebundleisonlyforthemidwifeservicesandthefee
forabirthcenter.Insomecases,themidwifestillmanagesthebirthevenifitisinthehospital,butthe
facilityfeeforthehospitalispaidseparately.
BlendedRateforHospitalLaborandBirth(RegardlessofDeliveryType):Severalpurchasersand
providersareimplementingepisodesframedspecificallyaroundhospitalbasedlaborandbirth,and
whichdonotincludecostsforprenatalorpostpartumcareorcareforthebaby.Thismodelblends
cesareanandvaginalbirthreimbursementratesintoablendedcaserateforhospitals.Theprimarygoal
istodecreasecesareanrates.Hospitalpaymentsandtheclinicalprofessionalfeesarethesameinthis
model,regardlessofthedeliverymethod.Theepisodepricealsoincludesthecostsofpostpartum
complications,butnootherpostpartumcostsareincluded.
AsdescribedinmoredetailinAppendixD,maternityepisodepaymenthasbeenassociatedwith
increaseduseofpreventiveservices,lowercesareanrates,lowerreadmissionandcomplicationrates,
andlowerearlyelectivebirthrates.
Recommendations:MaternityCare
DesignElements
ThedesignelementrecommendationsreflecttheCEPWorkGroupsresearchandanalysisonarangeof
existingepisodepaymentinitiativesforjointreplacement(see AppendixC).SeeChapter2,Episode
PaymentDesignElements,forasummaryoftherecommendationsdescribedin moredetailbelow.
45
1.
EpisodeDefinition
Theepisodeisdefinedtoincludethelargemajorityofbirths,
includingthenewborncare,thatarelowerrisk.Whilenotnecessarilylowerrisk,
episodepaymentmayalsobeconsideredappropriateforwomenwhomaybeat
elevatedriskduetoconditionsthathavedefinedandpredictablecaretrajectories,
suchasgestationaldiabetes.AstheCEPmodelmatures,somegroupswith
significanthighriskpregnancyexperienceandcapacitymayseekto
managetheentirecontinuumofrisk.
TheCEPWorkGrouprecommendsdefiningtheepisodetoincludeallservicesandcaredeliveredduring
threephasesofmaternity:prenatal,laborandbirth,andpostpartum(Figure7).Includingthesethree
phaseswithintheepisode,asopposedtonarrowlydefiningtheepisodearoundlaborandbirth,which
arearguablythecostliestaspectsofmaternitycare,iskeytoachievingthegoalsofepisodepayment.A
focusonlowerriskbirthswillhavesignificantimpactasthelargemajorityofbirthsareconsideredlow
risk.However,womenwithconditionsthatdevelopoverthecourseofthepregnancyorwhichhave
definedtrajectoriescanalsobenefit.Overtime,someproviderswhoareexperiencedwithhigherrisk
pregnanciesmayalsoseektomanagethecontinuumofriskunderneathaCEP.
Figure7:MaternityEpisodeDefinitionandTimeline
46
2.
EpisodeTiming
Theepisodeshouldbegin40weeksbeforethebirthandend60days
postpartumforthewoman,and30dayspostbirthforthebaby
Includingtheentirepregnancy,thelaborandbirth,andthepostpartum/newbornperiodwithinone
paymentrecognizestheimportanceofprenatalandpostpartum/newbornsupportforthehealthofthe
womanandherbaby.However,someepisodepaymentinitiativeslimitthetimeperiodfortheepisode
tohospitalcareonly,anduseablendedhospitalcaserate(blendingpaymentforvaginalbirthswith
cesareans)forlaborandbirth.Whilethisapproachhasbeenshowntodecreasetherateofcesareans,
thepotentialforimprovingonabroadersetofoutcomesencouragesamorewoman/patientcentered,
coordinatedapproachacrosssettings,andcouldbeincreasedbyincludingprenatalandpostpartum
careintheepisode.
The60dayspostpartumrecommendationwillallowforpostnatalfollowuptooccurandwillensure
thewomanreceivesneededphysicalandmentalhealthcareinasufficienttimeperiodtobeableto
takecareofherbaby.Alesseramountoftimeisrecommendedforthebabytoensurethat
accountabilitywaslimitedtonewborncare.
Consistentprenatalcare,inadditiontoprovidingcontinuouscareforthewoman,canidentifyhighrisk
markers,suchasgestationaldiabetes.Prenatalcarecanalsoincludechildbirtheducationtosupporta
womanthroughthementalandphysicalchallengesofvaginaldeliveryandprovideothersupports
duringpregnancy,givingbirth,andthetransitiontonewparenthood.Highqualitypostpartumsupport
canlowerreadmissionrates,increaseratesofbreastfeeding,reducepostpartumdepression,and
provideastrongfoundationforthewomanasacaregivertoherbabyandherfamily.
Theremaybeconcernsamongstakeholdersthatincludingprenatalandpostpartumcareintheepisode
canleadtodecreasedaccesstoorlimiteddeliveryofthoseservicesbyaprovidertryingtoutilizefewer
resourcestomaximizepotentialsavings.Anotherconcernregardingpostpartumcareiswhetherthe
clinicianwhomanagesthebirthshouldalsobeaccountableforthepostpartumperiod,particularly
whenthepostpartumperiodmayincludesomepediatriccare.TheWorkGroupbelievestheseconcerns,
althoughvalid,aremanageable.Forexample,someinitiativesrequirethecollectionandmonitoringof
certainperformancemetrics,suchasnumberofvisitsanddeliveryofcertainprenataltestsand
screeningbeforethebirthandtheprovisionofbreastfeedingsupportorcontraceptiveadvice
afterwardstoensuretheirdelivery.Concernshavealsobeenraisedaboutwhethertoincludewomen
whodonotopttoaccessprenatalcareorwhoaccessprenatalcarelaterintheirpregnancy.Toaddress
theseconcerns,onebundlinginitiativeadjuststheepisodedefinitionandpricebasedondiffering
numbersofprenatalvisits.Anotheroptionistoexcludewomenwhodonothaveaminimumnumberof
visitsfromtheepisodedesign.
Recognizingtheseconcerns,itisneverthelessoptimalformaternitycareepisodepaymenttoinclude
prenatalandpostpartumcareinadditiontolaborandbirth,inordertofullyleveragetheopportunityto
improvevalueandoutcomesacrossallthreephasesofmaternitycare.
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3.
PatientPopulation
Theepisodeshouldprimarilyincludethelargemajorityofbirths,
includingnewborncare,thatarelowerrisk.Whilenotnecessarilylowerrisk,
episodepaymentmayalsobeconsideredappropriateforwomenwhomaybeat
elevatedriskduetoconditionsthathavedefinedandpredictablecaretrajectories,
suchasgestationaldiabetes.AstheCEPmodelmatures,somegroupswith
significanthighriskpregnancyexperienceandcapacitymayseekto
managetheentirecontinuumofrisk.
Therearetwoissuesofparticularimportanceindefiningthepopulationintheepisode:whetherto
includenewborncareandwhethertoincludeallpregnantwomen,orasubsetoflessriskywomen.
IncludingtheBaby:Somecurrentmaternityepisodepaymentinitiativesincludethebaby,whileothers
includeonlycareforthewoman.TheWorkGrouprecommendsincludingthebabyintheepisode
population,giventhattheprimaryfocusoftheepisodeisthebirthandtheprimarygoalisbotha
healthywomanandahealthybaby.Stakeholderreadinesstoimplementmaternitycareepisode
paymentcanbeafactorindeterminingwhethertoincludethebabyinthepopulation.Inthebeginning
oftheseinitiatives,evenlimitingtheepisodetothechildbearingwomancanyieldimprovementsin
valueandmaybelesscomplexfortheprovidertoimplement.However,theWorkGrouprecommends
transitioningtoadesignthatincludesboththewomanandbabyassoonaspossible.
Theinclusionofthebabyintheepisodepopulationraisesissuesrelatedtoassigninganaccountable
entity(e.g.,whenmanagingthepregnancyrequiresaneonatologyspecialistinadditiontoorinsteadof
theOB/GYNorthemidwife).Althoughthesecasesarerelativelyrare,suchinstanceshighlighttheneed
forcooperationamongallprovidersacrosstheepisode,aswellastheneedforclearpoliciesonthelevel
ofriskwhentheprovideridentifiedastheaccountableentityhaslimitedabilitytomanagecareacross
providers.
DefiningthePregnancyLevelofRisk:TheWorkGrouprecommendsthat,atleastinthebeginningof
theimplementationofCEPmodels,the episode should primarily include the large majority of births,
including newborn care, that are lower-risk. The Work Group also supports CEP for women who may be at
elevated risk because of predictable risk factors that have defined care trajectories, such as gestational
diabetes. For both lower and elevated risk pregnancies, CEP may offer opportunities for better, safer care
at lower cost. As the CEP model matures, some groups with significant high-risk pregnancy experience
and capacity may seek to manage the entire continuum of risk.
ThereisampleopportunityinthisgroupofwomenforCEPtoprovideincentivestodiscouragetheuse
ofunnecessaryservicesandincreasetheuseofservicesthatareshowntobeeffectivebutunderused.
Beginningwithlowerriskpregnanciesalsoensureslessvariationinthecomplexityandtheriskthat
providerswillabsorb.However,theWorkGroupalsobelievesthatwomenathigherlevelsofriskcould
benefit.
Somehighriskpregnanciesintroducealevelofvariabilityandpotentialriskfortheaccountableentity
thatcouldbedifficulttomanage,particularlyforsmallpractices.Intheeventthatapregnancyresultsin
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ababywhorequiresintensivecare,stoplosspoliciesshouldbeestablishedtomitigatepotential
unanticipatedrisksoftrueoutliers.Criticaltotheepisodepopulationdesignelementisdefiningthe
exclusions.Definitionsvary,dependingonwhenduringthematernityperiodthedeterminationismade
andbywhom.
Definingrisklevelscanbedifficultbecausetheycanchangeoverthecourseoftheepisodeandcanbe
influencedbythecaredelivered.Initialdeterminationofwhetherawomanislowriskcanbemadeat
thefirstprenatalvisit,butitmaychangeovertime.HealthyPeople2020usesadefinitionforcalculating
lowriskforcesareanratesthatisbasedonfactorspresentimmediatelypriortobirthfullterm,single,
headfirstpresentation(OfficeofDiseasePreventionandHealthPromotion,2016;Stapleton,Osborne,
&Illuzzi,2013).Ahigherriskpregnancyisonewhichputsthemother,thedevelopingfetus,orbothat
anincreasedriskforcomplicationsduringorafterpregnancyandbirth.Clinicalparametersfor
identifyingahighriskpregnancycaninclude:
Preexistinghealthconditions,suchasdiabetes,hypertension,epilepsy,cancer,renaldisease,
obesity,advancedmaternalage,andmentalhealthconditions;
Lifestylechoices:Cigarettesmoking,alcoholuseandillegaldruguse;
Previouspregnancycomplications,suchasgeneticorcongenitaldisorder,stillborn,preterm
delivery;and
Pregnancycomplications,whichcanalsoariseduringthepregnancyandbirth,suchas:Multiple
gestation,fetalgrowthrestriction,prolongedprematureruptureofmembranes,orplacenta
abnormalities.
Asevidencedbythelistabove,someoftheexcludedcasesmaynotbeclearuntilafterthebirth.CEP
maybehelpfulineffectivelymanagingcomplicationsastheyarise.TheWorkGroupadvisesthose
designinginitiativestoconsiderthedifferentlevelsofriskanddevelopexclusionarycriteriaexclusionsof
importancetotheirpopulations.Ifthereisconcernovertheabilityforproviderstoaccepttheriskofa
higherriskpopulation,therearewaystolimitriskthroughriskadjustment,includingfactorsthatmight
ariseduringpregnancy.Stop/losslimitswillbediscussedinthediscussionontheLevelandTypeofRisk
below.SeeAppendixKforlinkstoresourcesthatprovidelistsofexclusions.
4.
Services
Coveredservicesincludeallservicesprovidedduringpregnancy,
laborandbirth,andthepostpartumperiod(forwomen)andnewborn
careforthebaby.Exclusionsshouldbelimited.Initiativesshould
alsoconsiderincludinghighvaluesupportservices,suchasdoulacare
andprenatalandparentingeducation.
Allservicescurrentlycoveredduringprenatalcarevisits,laborandbirth,postpartumcare,andnewborn
careshouldbeincludedaspartoftheepisodeservices.Thisincludesservicessuchasgenetictesting,
imaging,andanesthesiathataretypicallyprovidedtopregnantwomen.Wenotethetimeframefor
newborncareisshorterthanforwomanscare;thisisintentionaltolimittheservicesincludedinthe
49
pricetothoseneededtoaddressneonatalcareneeds.TheWorkGroupconsideredexcludingspecific
newbornservices,butdeterminedthatlimitingthetimeframeto30dayspostdischargewouldensure
thatthebulkofongoinghealthybabypediatriccare,suchasimmunizations,wouldbedeliveredoutside
thattimeframe.
Centraltotherecommendationofincludedservicesistheissueofcurrentlyunderusedservices.Some
underusedservicesaretypicallycoveredintodaysdeliverysystems,butothersarenot.Eachsetof
servicescreatesopportunitiesforeffectiveimplementationofamaternitycareepisodepayment
strategy.
CurrentlyCoveredbutUnderusedServicesNotDirectlyRelatedtoPregnancyandBirth:Some
initiativesseetheOB/GYN,midwife,orfamilyphysician,astheprimarycareproviderduringthe
pregnancy,birth,andpostpartumperiods,andviewtheprenatalcareperiodasanopportunityto
performpreventivescreenings,suchasforscreeningsforchlamydiaorcervicalcancer.Thesescreenings
arenottypicallyrelatedtopregnancy,butitmaybeimportanttoincludethemintheepisodeprice,as
theyarecommonlyprovidedtowomenaspartoftheirprenatalcareand,ifpresent,couldimpactcare
duringthepregnancy(AmericanAcademyofPediatrics,2013).Anotheroptionmightbetopay
separatelyforthemthroughFFS,butincludetheminepisodequalitymetrics,perhapswithapayfor
performanceincentiveinadditiontothebundledpaymentincentives.
CommonlyUncovered(andUnderused)HighValueServicesDirectlyRelatedtoPregnancyandBirth:A
varietyofservicesthathavebeenshowntoimproveawomansbirthexperienceandpotentially
improveoutcomesarenotcommonlypartoftypicalbenefitpackages.Oneimportantservicethat
clinicalepisodepaymentisdesignedtoencourageisgreatercarecoordinationacrossprovidersbythe
providersthemselves.Typically,providersareexpectedtoprovidesomelevelofthiscoordination
withoutadditionalreimbursement.Otherservicesnottypicallycoveredarethoseprovidedbydoulas,
carecoordinators(e.g.,forshareddecisionmaking,sharedcareplanning,communityreferrals,and
followuponsuchmattersassmokingcessation,mentalhealthreferrals,andcompletionofpostpartum
visits),groupprenatalvisits,andbreastfeedingsupport.Theuseofdoulasaloneorcontinuoussupport
forwomenduringchildbirthhasbeenassociatedwitha28%reductionincesareanbirth(Hodnettet
al.,2013).
Althoughbundlingcurrentlycoveredservicescouldresultinefficienciesandimprovedoutcomes,
providingincentivestoincreasetheuseoftheenhancedservicesdescribedabovemayleadtoeven
highervaluecare.Prospectivepayment(asdescribedinthePaymentFlowRecommendationbelow)
mayallowforgreaterproviderflexibilitytodelivertheseservices,asitdoesnotrelyonadirectpayment
fromthepayerforindividualcoveredservices.Evaluationoftheenhancedprenatalcaremodels
throughmaternitycarehomes,groupprenatalcare,andbirthcentersbeingtestedwithintheCMS
CenterforMedicareandMedicaidInnovationsStrongStartinitiativeprovideslessonsforthetypesof
servicesthatsupportmaternitycareepisodepaymentmodels(seePatientEngagement
recommendation).Regardless,itisimportanttomonitortheshiftinservicepatternstoensurethatthe
initiativeresultsinthehighestvaluecarefeasibleanddoesnotleadtounintendedconsequences,such
asrestrictingtheuseofimportantservicesbecauseoftheriskinvolvedintheepisodepayment.
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5.
PatientEngagement
Engagingwomenandtheirfamiliesiscriticalinallthreephases
oftheepisodeprenatal,laborandbirth,andpostpartum/newborn
tocontributetothefoundationforhealthywomenandbabies.
Engagingthepatientacrossthefullepisodeofmaternitycareprovidesimportantopportunitiesto
contributetomaternitycareepisodepaymentsuccess.Itisnotuncommonforpregnantwomentowant
tounderstandthechangestheyareexperiencingandtolearnaboutcareoptions.Manyprioritizebeing
involvedinmakingdecisionsabouttheircare.Theyaremotivatedtocontributetohealthyoutcomesfor
themselvesandtheirbabies.Moreover,giventhatmostareembarkingonalongperiodofhaving
disproportionateresponsibilityformanaginghealthcareacrossgenerations,theentirematernitycare
episodeisanoptimaltimetohelpwomenbecomeeffectiveusersofhealthcare.
Itshouldbestressedasearlyaspossibleinthematernityexperiencethatthewoman'schoiceofacare
providerandbirthsettingareinterrelated.Giventheextentofpracticevariation,understandingthese
choicescouldgreatlyimpacttheircareoptions,experiences,andoutcomes.Withthegrowthof
meaningfulpublicreportingofperformanceresults,andevidenceofwomensconsiderableinterestin
findingandusingsuchinformation,manywomenwouldbenefitfrombeingdirectedtorelevant
resourcesandhavingaccesstoguidancefromsomeonewhocouldhelpthemidentifyandinterpret
availableandrelevantcomparativequalityinformation(Declercqetal.,2013).Healthplansarewell
positionedtosupportwomeninthiswayand,asapregnancyproceeds,toencouragethemtoassess
whethertheirchosencarearrangementsprovetobeagoodmatchwiththeirvaluesandpreferences.
However,itisalsoimportantthatprovidersunderstandthechoicesawomanfacesinherareaandare
willingtohelphermakethem,becausenotallhealthplanswillbesetuptosupportthesediscussions,
andthewomanmaygofirsttotheprovider.Itmayalsobehelpfulforaprimarycareprovidertoassista
womaninthesedecisions.Thislevelofinvolvementcanhelpawomanobtainthetypeofhighquality
caresheprefersandfosterqualitybasedcompetitioninthemarketplace.
Afteramaternitycareproviderisselected,sharedcareplanningshouldbeintegratedthroughoutthe
episode,includinggoalsetting,shareddecisionmaking,anddocumentingpreferencesanddecisions,
withtheunderstandingthatcircumstancescanchangeovertime.Optimally,informationtechnology
makesthecareplanavailableacrosstheepisodeatallsitesofcareandtoallmembersofthecareteam,
includingwomenandfamilies.
Somepatientengagementeffortsinvolveenhancedservices,suchasthematernityhomeandgroup
prenatalvisitsbeingstudiedintheCMSsponsoredStrongStartdemonstration(CenteringHealthcare
Institute,n.d.;Hilletal.,2016).Inthematernitycarehomemodel,clinicalorcommunityhealthworker
carecoordinatorsareassignedtoworkwithpregnantwomentosupporttheirgoals,providereferralsto
communityresources(suchassmokingcessationprograms,childbirtheducation,mentalhealth
services,breastfeedingsupport),fostersuccessfulcaretransitions,andensurethatwomenattend
postpartumvisits.TheYear2StrongStartevaluationsuggeststhattheseenhancedservicesare
associatedwithadecreaseininterventionsthatarenotmedicallyindicatedandthatwomenare
pleasedwiththistypeofcare.StrongStartparticipantsexperiencingenhancedprenatalcareinbirth
51
centershadareductionincesareansandotherinterventions,hadstrongbreastfeedingresults,and
wereespeciallyhappywiththeirexperiences(Hilletal.,2016).Inthecontextofthisclinicalepisode
paymentmodel,acarecoordinatorisalsowellpositionedtoensurethatchildbearingwomencomplete
selfreportedsurveysofexperienceandoutcome.Inaddition,womenwhohaveaccesstodoula
services,includingprenatalandpostpartumsupport,experiencelowerfrequencyofcesareansections
andincreasedbreastfeeding(NationalPartnershipforWomen&Families,2016).
Highqualitychildbirtheducationclassesareanotherimportantwaytoengagewomeninlearningabout
optionsandmakinginformeddecisionsabouttheircare.Benefitpoliciesvary,butmanyMedicaid
programsincludechildbirtheducationasacoveredbenefit.HealthyPeople2020includesagoalto
increasethenumberofwomenwhoattendchildbirthclasses(OfficeofDiseasePreventionandHealth
Promotion,2016).Theseclassescandecreaseawomansfearsaboutlaborandbirthandareshownto
beacriticalfactorinreducingearlyelectivebirths.
Otherexamplesoftoolsforpatientengagementincludeshareddecisionmakingaids,suchasthe
decisionaidsdevelopedbytheInformedMedicalDecisionsFoundationand Childbirth Connection(now
availablethroughHealthwise)andtheuseofmobiledevices,includingText4baby,toaccesshealth
informationandservicesthatprovideindividualizedinformationbasedonthepregnancystageand
individualneeds.Anonlineinventoryidentifiesdecisionaidsbytopicratedaccordingtointernational
standards(OttawaHospitalResearchInstitute,2016).
Further,basedonthesuccessoftheOpenNotesproject,agrowingproportionofpatientsaregaining
fullaccesstotheirelectronichealthrecords(Belletal.,2015;Eschetal.,2016;Walker,Meltsner,&
Delbanco,2015).AnotherinitiativeMaternityNeighborhoodhelpscliniciansandwomen
communicateandqueryeachother,trackwomensprogress,scheduleappointments,andshare
educationalresources(MaternityNeighborhood,n.d.).Meanwhile,theinitiativeenableswomento
review,discuss,andcontributetotheirhealthrecord.Existingexperiencesuggeststhatfulland
interactiveaccesstohealthrecordsmaycontributetothesuccessofepisodepaymentmodels.Patient
portalscandeliverabroadrangeofuserfriendly,evidencebasedtoolsandeducationalresources.
Whilenotyetstandardpractice,awidevarietyofpatientengagementsupportisnowavailable(see
AppendixGforalistofresources,includingpatientengagementtools).
Thematernitycareepisodeshouldsupportthestandardizeduseofpatientengagementstrategiesand
models,particularlygiventhatthesestrategiesaretypicallyunderutilized.Infact,itmaybefeasibleto
encouragesomereinvestmentofaportionofoverallepisodesavingsintoservicesthatsupportsuch
engagement.Oneproviderdriveninitiativespecificallyincludedadditionalservicessuchasdoulasand
patientnavigatorsandfoundthemtobeofsignificantvalueinengagingpatientsandimproving
outcomes.8
Further,toconsistentlyimproveuponpatientengagementactivities,itwillbeimportanttousepatient
activationmetricstotrackoverallpatientengagement.AchangescoreforthePatientActivation
Measure(ahealthypersonversionrecentlyendorsedbytheNationalQualityForum[NQF])
administerednearthebeginningandendofpregnancywouldincentivizethoseparticipatinginthe
episodepaymenttobuildwomensskills,knowledge,andconfidenceastheyapproachgivingbirthand
newparenthood.
8ProvidenceHealthandServicesinitiative,articleandemailconversation.April2016.SeeAppendixDformoredetail.
52
Afinalapproachtoengagingwomenistocommunicate,inplainlanguage,thattheyarereceivingtheir
maternitycarewithinanepisodepaymentmodelandtoexplaintheimplicationsintermsoftheir
participationandhowthemodelaffectscostsharing,healthcarequality,andhealthcareoutcome.
6.
AccountableEntity
whatentityorentitiesshouldbeaccountable.Payersshouldworkwiththeaccountableentitytoassess
theirreadiness,andpromotecollaborationtoallowformultipleproviderswithinamaternitycareteam
tosharetheriskandrewardinsuchamannerthatallareengagedincreatingaseamless,efficient,
patientcenteredcareprocess.Thisprocesscanrequireactiveparticipationacrossthecontinuumby
aligningincentivesacrosscontractsintheprivatesector,becausethepayeroftenhascontractsdirectly
withproviders.
Whilelocalsituationswillvary,theCEPWorkGroupfavorscliniciansasthepreferredaccountable
entity.Theaccountablecliniciansaremorelikelytobeinvolvedthroughouttheentirepregnancy.In
addition,ifFFSrepresentsthepaymentmethodologywithretrospectivereconciliation,hospitalsmay
havelessofanincentivetodecreasepracticesthatprovidehigherreimbursementbecausethebulkof
thecostsforthisepisodelieinthelaborandbirthfacilityfees.
Optimally,accountabilitywouldbesharedamongallinvolvedproviders,ifincentivesarealigned.
However,itcanbedifficultfromalegalandfinancialperspectivetocreatethenecessarystructuresto
shareaccountability.Incircumstanceswheretheproviderisahealthsystemencompassingboththe
facilityandtheclinicians,accountabilitycouldmoreeasilybesharedbetweenthecliniciansandthe
facility.Somehospitalsownbirthcenters,andthismaybeanidealsituation.Oneinitiativebrought
togetherthefacilityandtheprovidersthroughabirthcenterastheaccountableentity.Inthisexample,
ifthewomanneedstogotothehospitalfortheactualbirth,thehospitalfacilityfeeispaidoutsidethe
bundle.Othersuseablended(vaginalandcesarean)caseratewithadiscountbuiltintoencourage
lowercesareanrates,and,inthesecases,holdthehospitalandcliniciansaccountableseparatelyforthe
partoftheepisodepricethatisallocatedforeach.InMedicaid,theprocessofsharingaccountability
maybeaffectedinstatesthathaveregulatorybarriersagainstoneproviderassigningpaymentto
another.Thisisdiscussedbelowaswell,inRecommendation7,PaymentFlow.
Anotherchallengerelatedtoassigningtheaccountableentityrelatestosituationsinwhichthenewborn
needsintensivecare.Insuchaninstance,thenewbornspecialistwilltakeoverasthecaremanager.
Whileweanticipatethatlimitingthepopulationtolowerriskpregnancies,stop/losslimitsandrisk
adjustmentmaylimittheriskoftheassignedaccountableentity.Itwillbeimportantfortheteamthat
managedthebirthtoincorporatethenewbornspecialistintotheprocess.
53
Insomecases,thepracticeresponsibleforthewomanscarebeforethebirthmaynotbeavailableto
managetheactuallaborandbirthorthehospitalmayusealaboristtomanagethebirth.Regardless,
thedeterminationoftheaccountableentityandalignmentandcoordinationacrosstheentireepisode
ofcaremusttakeintoconsiderationthespecificcontextinwhichthecareisdelivered.
Onequestionthatarisesinconsideringalternativestohospitalbirthsishowwidespreadtheavailability
isofbirthcentersorhomebirths.AccordingtotheAmericanAssociationofBirthCenters,thereare325
birthcentersinthenationin38states.Thereare11,114certifiednursemidwives,whopractice
primarilyinhospitals,butalsoinbirthcentersandhomebirths,with1,904certifiedprofessional
midwives,whomanagebothbirthcenterandhomebirths.Incontrast,therewere33,624OB/GYNsin
2010.Whilenotpresentinallregions,manywomenhaveaccesstotheselowercostbirthoptions,
whichalsoresultingoodbirthoutcomes(Cheyneyetal.,2014;HealthManagementAssociates,2007).
7.
PaymentFlow
thepaymentflow.Thetwoprimaryoptionsare:
1) aprospectivelyestablishedpricethatispaidasonepaymenttothe
accountableentity;or2)upfrontFFSpaymenttoindividualproviders
withintheepisodewithretrospectivereconciliation
andapotentialforsharedsavings/losses.
(Figure8).
InProspectivePayment,paymentisprovidedforthewholeepisode,includingallservicesand
providers,andpaidtotheaccountableentity,whosubsequentlypayseachproviderinturn.This
paymenttypicallyoccursaftertheepisodehasoccurredbutistermedprospective,asthepriceofthe
episodeissetinaprospectivebudgetaheadoftime,andthesavingsorlossesarenotsharedwiththe
payer;theyaresimplyafunctionofhowwelltheaccountableentity(andtheproviderswithwhomit
coordinates)managesthepredeterminedprice.InRetrospectiveReconciliation,individualproviders
areeachpaidonatypicalFFSbasisandthenthereisareconciliationbetweenthetargetepisodeprice
andtheactualaverageepisodepriceafteraperiodoftimeacrossalltheepisodesattributedtoa
provider.Basedonaspecificformula,whichiseithernegotiatedorestablishedbythepayer,the
accountableentitycanshareingainsand/orlosseswiththepayer.Insomeinstances,gainsorlossesare
alsosharedamongprovidersintheepisode,inordertoencouragecollaborationandcoordination
acrosssettings.Thesetypesofgainsharingarrangementsneedtobeconsideredwithintheparameters
offederallawsthatmayimpacttheirdesign,which isdiscussedinfurtherdetailintheregulatory
infrastructuresectionoftheOperationalConsiderationssectionofthisWhitePaper.
54
Prospectivepaymentisanoptioninsomecircumstancesparticularlywhentheaccountableentityisa
healthsystemthatalreadyintegratestheclinicianandfacilitypayment.Asapracticalmatter,itmaybe
moredifficulttoimplementasingleprospectivepaymentwhenmultipleprovidersinvolvedindelivering
thecaredonotalreadyhavemechanismsforadministeringpaymentamongthemselves,suchasisthe
caseinintegratedsystems.Increaseduseofprospectivepaymentcanacceleratedevelopmentof
varioussupportingmechanismstoaidinthisprocess.OnecautiononprospectivepaymentinaFFS
Medicaidprogramisthattheremayberegulatorybarriersforoneproviderassigningpaymentto
another.Legalcounselshouldbesoughtinthisscenario.However,retrospectivereconciliationiseasier
toadministerwithinourcurrentFFSenvironmentbecauseitrequiresfewerchangesfromcurrent
practicewheretheprevailingmodelisanopen,nonintegratedsystem.Inaddition,retrospective
reconciliationismoreprevalentincurrentepisodeinitiatives.Itdoesnotrequireproviderstodevelop
thecapacitytopayclaims,andallowsforbettertrackingoftheresourcesusedintheepisode.Italsocan
bebuiltonanexistingpaymentsystem.
Nevertheless,prospectivepaymenthasadvantagesinthatitisaclearbreakfromthelegacyofFFS
paymentandmayencouragegreatercoordinationandinnovationinepisodepayment.Forexample,ina
prospectivepaymentinitiative,itmaybeeasiertobeflexibleindeliveringotherwiseuncoveredservices,
suchaschildbirtheducationorcarecoordination,whichassistprovidersinachievingthegoalsoffewer
pretermdeliveriesandahigherlevelofvaginalbirths.Overall,itwillbeimportantforpayersinspecific
regionstocoordinatetheirstrategiesonpaymentflow,asitiseasiertoadministerforprovidersifthey
arepaidthesameway.
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8.
EpisodePrice
Theepisodepriceshouldstrikeabalancebetweenproviderspecific
andmultiprovider/regionalutilizationhistory.Thepriceshould:
2) reflectalevelthatpotentialproviderparticipantsseeasfeasibletoattain;and
3) includethecostofservicesthathelpachievethegoalsofepisodepayment.
Pricingepisodesinvolvessignificantcomplexity,bothtoassuretheaccuracyofestimates,andto
developapricingstructurethatisfairtoproviderswhileencouraginginnovation.Thegoalshouldbeto
establishapricethatencouragescompetitionamongproviderstoachievethebestoutcomesforthe
lowestcost.However,certainissuesneedtobetakenintoconsideration,includingaccountingfor
variationintheriskofthepopulation,theimpactofdifferingfeeschedulesandnegotiatingpower,
shiftsininsurersmidstream,regionalvariationinavailabilityoftypesofproviders,andensuringthat
paymentsaresufficienttoadequatelyreimburseforhighvalueservices.
Themonetaryrewardsorpenaltiesthatanaccountableentitymayexperiencearedeterminedinlarge
partbythemannerinwhichtheepisodepriceisdetermined.Inaddition,thereareseveralkeyaspects
thatinteractintheestablishmentoftheepisodeprice.Allpayerswillexpectsomereturnontheir
investmentsinthispaymentdesign,andcanchooseavarietyofmechanismstogeneratesomelevelof
savings.Itisalsoimportanttoconsiderincludinginthetargetepisodepricecostsforhistorically
underusedservices,asdiscussedinRecommendation4,andadditionalservices,suchasapatient
navigator/carecoordinator,groupvisits,adoula,orbreastfeedingsupport.Further,whethertobuildin
savingsforimprovements,suchaslowercesareanrates,isalsoaconsideration.
Typically,thetargetepisodepriceissetusingsomecombinationofregionalandproviderspecificclaims
dataforaperiodoftimethatincludesasufficientnumberofcasesusedinestimatesforthecoming
year.Insomecases,thepayercanalsoincludeanestimateofadecreaseincostsbasedonquality
improvements,suchaslowercesareanratesorlessneedforNICUcare.TheWorkGrouprecommends
balancingregional/multiprovider9andproviderspecificcostdata:
BalancingRegionalandProviderSpecificData:Costdatashouldreflectamixofproviderandregional
claimsexperience.Thegoalofincludingregional,ratherthanmarketleveldata,istoensurethatthereis
enoughvariationinepisodecost.Thismixwillalsoensurethattheestablishedepisodepricetakesinto
considerationtheuniqueexperienceofthespecificprovider,andthatthegoalsaresetbasedonwhatis
feasibleintheregion.Riskadjustmentwillbeneededduringthisprocesstoadjustfortheunique
characteristicsofthepopulationtheproviderserves.Ifthepayerisanationalpayer,itmaybemore
difficulttoaddressspecificproviderissuesandwillrequireconsiderationoftheuseofnationalclaims
experiencetoensureequityacrossregions.Overtime,asperformancebecomeslessvariable,itmaybe
Forpurposesofthispaper,regionisnotdefined.Theregionwillbedefinedasacombinationoftheexperienceof
multipleproviders.Weusethetermregionaltoreflectthisassumption.
56
usefultolessentheproportionoftheepisodelookbackperiodthatisbasedontheorganizations
specificexperience.
RegionalCosts:Usingregionlevelclaimsdataallowsthepayertotakeintoaccountthecostsofmultiple
providerswithinaregion,reflectingthefactthatoneproviderscostsmaynotberepresentativeofthe
entireregion.Italsoaddressesthevariabilitythatmayexistforaproviderwithalowvolumeofcases.
However,theconcernwithusingregionalclaimsisthat,ifasawhole,providersinthatregionhave
alreadyachievedacertainlevelofefficiency,theymaybelessabletoachievefurthersavings.In
essence,theseregionsortheprovidersinthemwillarguethatanefficientregionwillbepunished
foritspreviousworktoachievetheseefficiencies.Ontheotherhand,iftheregion,onaverage,hasa
higherperbundlecostthanotherregions(orspecificproviderswithintheregion),thepayermaynot
achieveasgreatalevelofsavingsthaniftheepisodepricewastobesetatanationalorprovider
specificlevel.Whilebasingsomepartofthepriceonregion,itisalsoimportanttonotevariationacross
regionsandtoconsiderwhethervariationacrosstheregionsiswarrantedornot.Itisimportanttolook
atthisclosely,andnotjustbakeinregionalvariationifthereisnotobjectivereasonfordoingso.
ProviderCosts:Providerspecificcostsaretheactualcostsfortheproviderspreviouspatients.For
example,iftheOB/GYNpracticeistheaccountableentity,thepayerwouldconducttheanalysisusing
thecurrentepisodedefinitionandapplyittoitspregnantpatientsoverthepasttwoyears.The
challengeisthatalthoughthesecostsmaybeaccurateforagivenclinicalpracticewithagivenpayer,
theymaybuildinexistingefficienciesthatmakeitmoredifficulttoachievesavingsorleaveinplace
builtininefficienciesthatlimitthesavingsforthepayer.
Onechallengeinmaternitycareisthatdifferentprovidersmayhavedifferentepisodecosts.
Consequently,payersmaytakevariousapproachestoepisodepricingasafunctionofotherfactors,
includingnetworkconfiguration,benefitincentives,andpreferredmechanismsforcomingtoagreement
onpricing.Forexample,becausethereissignificantvariationincesareansectionratesacrossproviders,
aswellasvaryingprices,payerswillneedtodeterminewithwhichproviderstheywanttobasethe
episode.Determiningwhatlevelofcesareanratetobuildintothepricewillvarybasedonthepayers
networkandnegotiatingpower,oritmayimpactthedecisionsthepayermakesregardingwithwhich
hospitalstocontract.Itisalsothecasethatservicesdeliveredatonehospitalmaybemoreorless
expensivebasedonthefeestheyhavenegotiatedwithpayers.Anotherexampleofachallengespecific
tomaternityistheabsenceofuniformbillingcodesforbirthcentersacrosspayers.Thismayrequirea
benchmarkingprocessthatutilizesdifferent,orproxy,billingcodes.
Significantvariationincostsbetweenhospitalsandbirthcenterscanalsogreatlyimpactepisodecost.
Researchincreasinglyrevealsthatbirthsmanagedbymidwivesandbirthsinbirthcentersarenotonly
lessexpensivethanhospitalbirthsbutalsooftenleadtothesame,ifnotbetter,outcomes(Howell,et
al.,2014;Johantgenetal.,2012).Ifawomanchoosestogotoabirthcenter,thecoststructureis
significantlylowerthanifshechoosestogivebirthinahospital.Astrategymightbeonewherethe
payerbuildsanetworkeitherwithhospitalsthathavelowercesareanratesorwithincentivesfor
womentomorefullyutilizeandexpandaccesstobirthcentersintheirregion.Thebundledpricecould
bebasedonthatlowerintensitybirthmodel,butmayonlyapplyinthatsetting.
57
improve.
category.
dosowilldependontheavailabilityofdataandanalytictools.Theseinclude:
haveasignificantimpactonapatientshealthstatuspriortopregnancy,accesstocare,andpost
partumoutcomesforthewomanandthebaby.Theseincludeincome,literacystatus,livingstatus(living
alone,livinginacommunitywithoutfamilyorothersupportsnearby),andavailabilityoftransportation
(bothingeneral,andtocaresettings),amongothers.Certainsocioeconomicfactorsmayalignwitha
specificpayercategory,whetheritbeMedicaidorcommercialpayers.
publicpayer,ifpaidonaFFSbasis.ManagedcareplansinMedicaidandMedicarewillnegotiatewith
providers,astheydointhecommercialmarket.Eitherway,thiswillimpactthelevelatwhichthe
episodepriceisset,aswillthemarketinwhichthepayeroperates.Ifparticipationisvoluntary,some
formofnegotiationwillbenecessarywhetherthroughdirectdiscussion,orthroughthepublicprocess
ofrulemaking.Iftheinitiativerequiresparticipation,itmaybeeasiertodetermineanepisodeprice.
However,thepricewillneedtobeonewhichisrealisticforproviders.
fromatrustedsource.Theavailabilityofthesedatatoidentifytheopportunitiesforefficiencyiscritical
tothesuccessoftheseinitiatives.
theirpatients,aswellasbetweenpurchasersandtheiremployees.Forfurtherdiscussiononthistopic,
pleasereadthepaperonFinancialBenchmarking,clickhere.
58
9.
TypeandLevelofRisk
Transitionperiodsandriskmitigationstrategiesshouldbeused
toencouragebroadproviderparticipationandsupportinclusion
ofasbroadapatientpopulationaspossible.
Thegoalwhensettinganepisodepriceshouldbeto
incorporatebothupsiderewardanddownsiderisk.
Withoutdownsiderisk(wheretheactualcostsexceed
thetargetepisodeprice),theaccountableentityand
otherinvolvedprovidershavelessincentivetomake
thenecessarycareredesignchangestocreate
efficienciesandimprovepatientcare.Further,
increasesinthecostofcaredeliveryfromyeartoyear
cannegatethebenefitsofupsidesharingofsavings
becauseoftherelianceonhistoricaldata.Prospective
paymentbydefinitionincludesboth.Retrospective
reconciliationwithupfrontFFSpaymentcanbe
designedtoonlyshareinsavings(upsidereward)orto
shareinlosses(downsiderisk).Insomecases,payers
willbeginwithupsiderewardsharingtoallowforthe
providertoestablishtheinfrastructureandreengineer
carepracticestobecomecapableofmanaging
downsideriskinthefuture.
Aprimarygoalindesigninganyalternative
paymentmodelarrangementisguarding
againstunintendedconsequences.In
episodepaymentformaternitycare,the
unintendedconsequencethatconcernsall
providersbutperhapssafetynet
providersmostofallisthepotentialfor
decreasedaccesstocareforpatientswith
poorhealthstatus,whichputsthemat
increasedriskforpooroutcomes.Thismay
becorrelatedwithlowersocioeconomic
statusiftheproviderfeelsthatitwillnotbe
possibletoprovidethefullcontinuumof
careandachievepositiveoutcomeswithin
theepisodeprice.Safetynetprovidersin
particularmayneedtimetodevelop
adequatereportingandstaffing
infrastructure;andbuildrelationships
acrosshistoricallysiloedorganizationsin
ordertofeelpreparedtotakeontheriskin
anepisodepaymentmodel.
However,takingondownsideriskmaybedifficultfor
smallerproviders,includingmanyOB/GYN,family
physician,andmidwifepracticesthataretheproviders
bestabletosupportanewmodelofmaternitycare.
Further,inclusionofdownsideriskmaybeabarrierto
providerparticipationwhentheinitiativeisvoluntary.
Itisimportanttoacknowledgethatseveraloftheprimarygoalsofthematernitycareepisode(for
example,decreasingcesareanandNICUuse)willresultinlowerperpatientreimbursementforthe
hospital.Thismeansthatiftheclinicianpracticeistheaccountableentity,andthereisnoupsidereward
ordownsiderisktothehospitalwherethemajorityofbirthswilloccur,thentheprovidersthe
cliniciansandthefacilitieswillhaveverydifferentincentivestructures.Thissourceoftensionwillneed
tobeexplicitlyaddressed,possiblythroughsometypeofsharedaccountability,whichincludesthe
abilitytoshareinthesavingsorriskforanypotentialloses.
Toaddressconcernsrelatedtothelevelofrisk,payerscanutilizestrategiestolimitthatriskorto
transition(phasein)todownsideriskarrangementsovertime.Thisisparticularlyimportantifthe
initiativeisvoluntaryandparticipationwouldbelimitedwithouttheoptionforupsidesharedsavings
only.Decisionsabouttype,level,andtimingofupsideanddownsideriskillustratethetensionsbetween
59
payersandproviders:moreattractiveriskarrangementsforpayersmaybelessattractiveforproviders
andviceversa.Consequently,intheprivatemarket,thesefactorswillbecomepartoftheongoing
negotiationsamongnetworkparticipantsandpayers.Inpublicprograms,thesenegotiationswillhappen
throughthepoliticalandpolicyprocessofrulemaking.
MechanismsforLimitingRisk
Thelevelatwhichthoserisklimitsaresetisacriticaldesignelement.Thereareseveralissuesto
consider,suchaswhethertheaccountableentitywillberequiredtopaythefulldifferencebetweenthe
totaldollarsovertheestablishedepisodepriceandtheactualepisodecostsbacktothepayer,or
whetherlimitswillbeestablished.Limitsareespeciallyimportantconsideringthatanaccountableentity
isaccountableforcareprovidedbyotherproviders.Inthecaseofmaternitycare,thefacilityaccounts
forthelargestpercentageofoverallcosts.Whattheaccountableentity(theclinicianpractice)ispaid
throughFFSpaymentislimitedcomparedtotheliabilityassociatedwiththeentirecostoftheepisode
overtheestimatesfortheentirepopulationofincludedbirths.
Oneriskmitigationstrategyalreadyaddressedislimitinghighriskcasesthroughexclusions.Following
areadditionalstrategiesusedbyvariousinitiativestolimitriskinanepisodepaymentwhilestill
maintainingasbroadanepisodepopulationasisfeasible.Theseareoften,butnotalways,usedin
tandem.
RiskAdjustment:Riskadjustingtheepisodeprice,basedontheseveritywithinthepopulationinthe
maternitybundle,isoneriskmitigationstrategy.Mostinitiativeswillincludealistofincludedand
excludedwomenandthenalsohavealistoffactorsthatwouldbeusedtoadjusttheepisodeprice.
Thereareavarietyofapproachestocapturingpatientcharacteristics,riskfactors,andotherparameters
thatpredictmaternitycareepisodeexpenditures.Forexample,theHealthCareIncentivesImprovement
Institutes(HCI3)evidencebasedcaseratescreateavarietyofpatientspecificepisodesthatrecalibrate
basedonvariouspatientspecificseverityfactors.ThematernitybundlesinTennesseearealsoadjusted
basedonavarietyoffactors,includingriskand/orseverityfactorscapturedinrecentclaimsdata,such
asearlylabor,preeclampsia/eclampsia,andbehavioralhealthconditions.Althoughriskadjustment
methodsarelimitedintheirpredictiveaccuracybasedonclaimsalone,overtime,thesefactorsand
theirweightscanbeupdatedtobecomemoreaccuratebasedonempiricalexperience.Atthesame
time,werecognizethatriskadjustmentcanpotentiallyleadtogaming.Forexample,aprovidermay
adoptmoreintensivecodingtoeitherincreasethereimbursement,ortoensurethepatientisnot
includedinepisodepopulation.Oraprovidermayrefermoredifficultpatientstootherpracticestolimit
theirownpaneltoonlythelowestriskwomen.Thiswillneedtobemonitoredtoensurethatcodesare
notbeingoverusedtoobtainhigherpaymentsratherthantoaccuratelyreflecttheconditionorriskof
thepregnancy.Forfurtherdiscussiononthistopic,pleasereadthepaper onFinancialBenchmarking,
clickhere.
StopLossCaps,RiskCorridors,andCapitalRequirements:Stoplosscapsarealreadydiscussedinthe
contextoftheincludedpopulationasonewaytolimittheriskofveryhighcostnewbornsatan
individualpatientlevel.Stoplosscapsalsocanbeusedonanaggregatelevelacrossthepopulation.Risk
corridorslimittheexposureoftheaccountableentitybyestablishinganupperlimitoverwhichthe
accountableentitywillnothavetopaybackanyamountofdollarstheoverallcostsoftheepisodesmay
goovertheestablishedepisodeprice.Thesecorridorscanalsobeplacedontheupsidereward,such
thattheincentivestolimitcarearenotasgreatastheywouldbeotherwise.Anotherriskmitigation
strategyistorequiretheaccountableentitytomaintainacertainlevelofcapital,sothatitcancover
60
lossesandinvestinnecessaryinfrastructure.Whilethesetypesofarrangementsareoftenusedtolimit
insurancerisk,thesameconceptscanalsobeusedinthiscontexttolimitservicerisk.
10. QualityMetrics
Prioritizeuseofmetricsthatcapturethegoalsoftheepisode,including
outcomemetrics,particularlypatientreportedoutcomeandfunctional
statusmeasures;usequalityscorecardstotrackperformanceonquality
andinformdecisionsrelatedtopayment;andusequalityinformationandother
supportstocommunicatewith,andengagepatientsandotherstakeholders.
Awidevarietyofmeasuresareinuseformaternitycarethatcouldbeusedtosupportthegoalsand
operationofclinicalepisodepayment.Atthistime,theWorkGroupdoesnothavespecific
recommendationsforthemosteffectivemeasures,butratherprovidesexamplesofthetypesof
measuresofmaternityandnewborncarequality.TheWorkGroupalsonotestheimportanceofthe
developmentofpatientreportedoutcomesandfunctionalstatus(particularlypostpartum)measures.
Thosealreadyimplementingmaternitybundlesuseavarietyofmetrics,butthereseemstobetwo
primarycategoriesorstrategies.First,therearemeasuresofwhethercertainprocessesorserviceswere
providedduetoconcernsthattheymightbeunderutilizedabsentsomemechanismforaccountability
andbecausetheyarepracticesknowntoimproveoutcomes.Theseincludemeasuressuchasthe
numberofprenatalvisits,screeningtests,breastfeedingsupport,anddepressionscreening.Secondare
measuresofoutcomes,whichcancorrelatetochangesincaredelivery.Theseincluderatesofvaginal
births/cesareans,pretermandearlyelectivebirths,ratesofepisiotomy,exclusivebreastfeedinginthe
hospital,andpatientcomplications.Thesetwocategoriestogethercancapturethequalityofcare
deliveredintheprenatal,laborandbirth,andpostpartumtimeframe.
Inselectingthemetricsforanepisodepaymentmodel,itisimportanttorecognizethepreferencefor
alignmentofmeasuresacrossprograms,useofnationallyendorsedmeasures,andalimited,tightsetof
measureswithalowburdenofcollection.TheWorkGroupsupportstheseprincipleswhenevertheycan
bemetwithmeasuresthatincentpriorityopportunitiesforimprovingmaternitycare.Ameasurethat
meetsthesecriteriawithoutthepotentialforhighimpactamongchildbearingwomenandnewborns
wouldnotbeusefulforthispurpose.
PotentialMeasures:Inthespiritofbuildingonexistingmeasurementconsensusprocesses,theWork
GrouprecommendsconsiderationoftheapplicablemeasuresrecentlyreleasedfromtheCoreQuality
MeasuresCollaborative(CQMC)thatcouldbeusedinthematernitybundle(CentersforMedicareand
Medicaid,2015a).MeasuresintheCQMCOB/GYNCoreSetthatareonlyapplicabletogynecological
careandnotobstetriccarearenotincludedhere.However,measuresinthecoresetthatmaynotbe
considereddirectlyrelatedtomaternitycarebutareoftendeliveredeitherduringtheprenatalor
postpartumperiodareincluded.TheCQMCdividedthesetintoaccountabilityfortheOB/GYNandfor
thehospital/acutecaresetting,buttheycouldalsobeusedforqualitymeasurementofanepisodeof
care.
61
CQMCmeasuresrelatedtotheambulatoryOB/GYNsettinginclude:
Frequencyofongoingprenatalcare;10
Cervicalcancerscreening;and
Chlamydiascreeningandfollowup.
CQMCmeasuresidentifiedforthehospital/acutecaresettingsinclude:
Incidenceofepisiotomy;
Electivedeliveryforvaginalorcesareanat>=37and<39weeksofgestationcompleted(PC01);
Cesarean(nulliparouswomenwithaterm,singletonbabyinavertexpositiondeliverybycesarean
section,PC02);
Antenatalsteroidsundercertainconditions(PC03);and
Exclusivebreastmilk(PC05).
CMSMedicaidandCHIPChildandAdultCoreMeasuresforMaternityCare:AsillustratedinTable7,
CMSworkedwithstateMedicaidagenciestodevelopacoresetofchildandadultmeasuresthatinclude
somematernitymetricsofimportancetothatcommunity.
Table7:MedicaidandCHIPChildandAdultCoreMeasuresforMaternityCare11
Source
AdultCore
ChildCore
CQMC
PC01:Electivedelivery
NQF0469
PC03:Antenatalsteroids
NQF0476
TimelinessofPrenatalCare
NQF1517
PC02:CesareanSection
NQF0471
Livebirthslessthan2500grams
NQF1382
Frequencyofongoingprenatalcare
NQF1391
Behavioralhealthriskassessment
forpregnantwomen
AMAPCPI
PediatricCentralLinkedAssociated
Bloodstreaminfections:neonatal
ICUandpediatricICU(CLABSI)
NQF0139
10
Status:ThismeasurewasrecentlyrecommendedforremovalofNQFendorsedmeasuresandtheMedicaidcore
setbyTheNQFPerinatalandReproductiveHealthStandingCommitteeandtheNQFMAPMedicaidChildandAdult
TaskForces
11
TheNQFMAPMedicaidChildTaskForcevotedtorecommendinclusionofPC05ExclusiveBreastMilkFeeding
(NQF0480)andtheequivalentPC05eMeasure(NQF2830)intheChildCoreSet.
62
Postpartumcontraceptiveuse
amongwomenages1544
Source
AdultCore
ChildCore
CQMC
Developmen
talmeasure
(OPA/CDC)
NQF290212
Likelytobe
includedin
futuresets
OtherPotentialMeasures:
ThegenericConsumerAssessmentofHealthcareProvidersandSystems(CAHPS)patientexperiencesof
carefacility,clinician,andhealthplanmeasuresdonotmapwelltoantenatalthroughpostpartumand
newborncareandthispopulation.However,theremaybespecificCAHPSsupplementalitemsthat
couldbeofusetomeasurepatientexperience(AgencyforHealthcareResearchandQuality,2016).
Tomeasureexperienceofcarewithinitsepisodepaymentmodel,CommunityHealthChoice,a
maternityclinicalepisodepaymentinitiativeinTexasMedicaid,developedasurveybyselectingitems
primarilyusedinpreviousnationalListeningtoMotherssurveys.Topicsincludedthetimingand
communicationexperienceinprenatalcare,planningforthebirth,andthemothersexperienceafter
thebirth,whichincludescaregiverfollowupandheroverallsatisfactionwiththeexperience.
Functionalstatus,particularlyafterbirth,whenusedtocapturesuchselfreportedoutcomesaspain,
abilitytoperformactivities,anddepressionalsoneedsmorefocus.Itisatimeperiodthatsetsthestage
forthehealthoftherecoveringwomanandhernewborn.Functionalstatusinstrumentsarenot
routinelyusedintheinitiativeswehavereviewed,buthavebeenusedforpostpartumresearch,and
couldbedevelopedintosurveyinstrumentsforthiscontext.Researchonthesefunctionalstatussurveys
demonstratetheirabilitytomeasurepostpartumhealth.
Ameasureofpatientskills,knowledgeandconfidenceinmanagingoneshealththePatientActivation
Measure(NQF#2483:GainsinPatientActivation(PAM)Scoresfrom612months)woulddemonstrate
whetherthehealthsystemhasprovidedopportunitiestoincreaseactivationfromearlytolate
pregnancy.
Severalothermeasuresarealsoofinterest,includingratesofunexpectednewborncomplicationsand
ratesofvaginalbirthaftercesarean.Ratesofnewborncomplications,particularlyunexpected
complications(e.g.NQF0716),measuretheultimateoutcomeofthebirththebabyshealth.A
measureofthevaginalbirthaftercesarean(VBAC)rate(e.g.AHRQIQI134)couldaddressanimportant
opportunityforimprovementthatwouldbecomplementarytotheabovementionedcesareanrate.
Further,provisionofinfluenzavaccinesprenatallyalsohasbeenshowntodecreasecomplications.
Thesemeasuresarenottheonlyonesthatvariousinitiativeshaveused,andeachinitiativemaywantto
customizeitsqualitymetricstosomeextent,dependingontheneedsofitspopulation.
QualityScorecard:Acorefeatureofanyepisodepaymentinitiativeisusingperformancemetricsto
createscorecardstoensurehighqualitycaredelivery;informthedecisionsofthewoman,herfamily,
andherproviders;anddeterminepaymentlevels.
meetorexceedinordertoreceivethefullreimbursementforanepisodeorthefullsharedsavings.
12
Status:NQFReproductiveHealthStandingCommitteerecommendedendorsementofthismeasureinMay2016
andiscurrentlygoingthroughconsensusdevelopmentprocess.
63
However,thedecisiononwherethosethresholdsaresetorhowtheyareusedshouldbeleftforthe
payerandprovidertonegotiate.Someinitiativesvarythelevelofsharedsavingsbasedonperformance
metrics,whileothersalsouseminimumperformancelevelsasathresholdforreceivinganyportionof
thesavings.Inaprospectivelypaidinitiative,itmaybeusefultowithholdsomeportionofthe
prospectivepaymentandbaseitspaymentorlevelofpaymentonperformanceonthequality
scorecard.
QualityInformationtoCommunicateandEngagewithPatients:Inadditiontousinginformationon
qualitytodeterminepayment,itisimportanttootherstakeholderstohaveaccesstodataonquality.As
discussedunderPatientEngagement,womenneedqualitydataontheperformanceofdifferent
facilitiesandonmaternitycareproviderstoinformtheirchoices.Currently,dataonmaternitycare
providerperformancearenotroutinelyavailableanddevelopmentisneededtosupportmore
widespreadandroutinedatacollection.
Comparativequalityinformationisalsoimportantforproviderstousetoimprovetheirperformance.A
providerportal,separatefromelectronichealthrecords(EHRs),whereproviderscanaccessindividual
averagequality,costs,andutilizationacrossepisodes,isonewaytoprovidethisinformation.The
Arkansasinitiativefoundthistypeofportaltobeimportantforproviders.
Employers,purchasers,andpayersalsoneedthesedatatodevelopprovidernetworksandtohelp
employeesmaketheseimportantchoices,bothbeforeandduringpregnancy.Specifically,employees
needtounderstandthebundleandwhattheirroleisinreceivinghighqualitycare.Primarycare
providershopingtoenterintobundledpaymentcontractswillwantdataaboutspecialtyphysician
qualityperformanceinordertodeterminewhichbundledarrangementswouldbemostbeneficialto
theirpatientpopulation.
Finally,episodepaymentdesignmustbuildinthecapacitytocollect,analyze,andprovidedataand
supportpatientsinidentifyingandinterpretingthisinformation.Theuseofpatientnavigatorsfor
whomsomeexistinginitiativeshavesubstitutedcommunityhealthworkerscanbehelpfulinproviding
thissupport.First,however,theinformationitselfmustbeavailable.Itisimportant,therefore,to
establishcrosscuttingeffortstodefinemetricsandsystemsfordatacollectionandanalysis.Itisa
significantburden,however,foreachinitiativetodefineitsownmetrics,collectionsystem,and
scorecard.Broadereffortsareneededtobuildthenecessaryinfrastructureformeaningfuldevelopment
anduseofqualityperformanceinformation,andbuildingthese systemsisoneofthekeychallenges
discussedintheOperationalConsiderationssectionofthisWhitePaper.Toread moreabout
PerformanceMeasurement,clickhere.
64
Insertcoverpage
65
Chapter5:CoronaryArteryDisease
Background
AccordingtotheNationalCenterforChronicDiseasePreventionandHealthPromotionsDivisionfor
HeartDiseaseandStrokePrevention,coronaryarterydisease(CAD)isthemostcommontypeofheart
diseaseinAmerica.IntheUnitedStatesin2010,about20%ofthe65yearoldandoverpopulationwere
livingwithCAD.Thisconditionisalsopresentinabout7%ofthepopulationwhoarebetweentheages
of45and64.PatientswithCADoftenexperiencecomorbiditiessuchasdiabetesandobesity.Thetwo
proceduresmostcommonlyusedtotreatCADpatientsPCIandCABGaccountformorethanone
millionproceduresdoneannuallyintheUnitedStates.Thisamountedtoacostofmorethan$15billion
ofhealthcarespendingin2012.Thesefiguresdonottakeintoaccounttheadditionalcostsof
hospitalizationbeforeandaftersurgery;accordingtotheU.S.CentersforDiseaseControl,theaverage
costofhospitalizationforacoronarybypassin2013was$38,707perperson.Thenationalexpenditures
forCADrelatedhospitalizationin2013cametoatotalof$6.4billion(CentersforDiseaseControland
Prevention,2014).
PatientswithCADexperiencetheirillnessinmanydifferentways.Somepatientsarediagnosedduetoa
triggeringevent,suchasanacutemyocardialinfarction(AMI)orheartattack.Othersarediagnosed
followingeitheracuteorroutinediagnostictestingthatresultsineithertheneedformedical
managementoraprocedurelikePCIorCABGsurgery.WhileCADhasavarietyofmanifestationsand
acuities,acommonthreadthattiesalmostallCADpatientstogetheristhefactthatCADisachronic
condition;thosewhoarediagnosedwithitwilllikelyhavetolivewithitfortheremainderoftheirlives.
Thewayinwhichapatientisfirstdiagnosed,aswellasthesettinginwhichcareisdelivered,canhave
animpactonthecostandintensityoftreatment.IncaseswhereapatientneedsaCADrelated
procedure,multipleprovidersparticipateineachpatientstreatmentcourse.Thiscanleadto
fragmentedanduncoordinatedcare.Forexample,thetypicalsettingsforCADcareincludeprimaryand
specialtycaresettings;hospitalinpatientandoutpatientsettings;postacutecarefacilities,suchas
cardiacrehabilitationcenters;andpatientshomes(viahomehealth).PatientsmayreceiveCADcarein
morethanonesettingastheirtreatmentevolvesovertime.Currently,eachofthesesettingsreceives
paymentseparatelyfortheservicestheyprovide.Therearefewincentivestosupporttheprovisionof
caremanagement,preventiveservices,efficientandsparinguseoftestsandprocedures,and
coordinationofcareacrossthesediversesettings.Thislackofcoordinationandincentivesfordelivering
highvaluecareacrossthecontinuumtoooftenresultsinrelativelyhighratesofadversedrugevents,
hospitalindexadmissionsandreadmissions,diagnosticerrors,andlackofappropriatepreventive
servicesandfollowuptestingforpatientswithCAD(Riegel,n.d.).
ItisforpreciselythisreasonthattheCEPWorkGroupchosetodevelopaconditionlevelepisodemodel
forthemanagementofCAD.WhilePCIandCABGprocedures,andincidencesofacuteAMI,are
significantdriversofCADrelatedcosts,patientswithCADneedamorecomprehensiveapproachto
managingtheirconditionsandseekingpositiveoutcomesthathelppreventtheneedforprocedures.A
numberofgoalsassociatedwithimprovingoutcomesforCADpatientsarebeyondtherealmofaPCIor
CABGprocedure;foreachgoal,thereareleversthatcanbemovedusingthetypesoffinancial
incentivesinherentinepisodepayment(Table8).
66
Table8:AvailableLeversforAchievingOutcomeGoals
SystemLevel
Levers
Goals
Increasingtherateofprovisionof
therightcareattherighttimein
therightsetting
Deliveryofimagingdiagnosticsand
lowacuityproceduresinthemost
appropriateandefficientsetting
Reducingavoidablecomplications
Reducingunwarrantedand
unjustifiablevariationincare
Providingoptimalmedication
management
Coordinatedandinnovativecare
transitionprocesses
Improvingqualityoflifefor
patients
Innovativedeliveryofcoordinated
preventivecare
Increasingsymptomfreedays
Diseasemanagement
Reducingacutemyocardial
infarctions
Lifestylechanges
Patientcentereddischargeprocesses
Coordinationofpostacutecare
Coordinatedandinnovativecare
transitionprocesses
Rapidreturntonormal
activities
PatientLevel
Increasingpreventivecareand
preventingacuteeventsthat
resultinhospitalization
Increasingpositiveoutcomesfor
acutecarepatients
TheValueofEpisodePaymentforCAD
TraditionalFFScreatesincentivesforprovidingahighquantityofservicesandtreatments,potentially
rewardingboththeuseofexpensivetreatmentsandtestsregardlessofvaluetothepatient,and
avoidableinvasiveproceduresandhospitalizations.EpisodepaymentforCADestablishesabudgetthat
incentivizestheprovidersmanagingthepatienttomoreappropriatelybalancetheneedsofthepatient
andthenumberandtypeofservicesprovided.Placingaccountabilityfortheentireconditionwitha
designatedprovideralsoencouragestheactivemanagementofthepatientinordertopreventacute
eventsthatleadtoworseninghealth,furtherprocedures,andanincreasedriskofoverallpoor
outcomes.Thegoalofpersoncenteredepisodepaymentistomakethepatientthefocusofcare
management,ensuringthatanyefficienciesachievedthroughimprovedcarecoordinationand
managementfirstandforemostbenefitthepatient.
Placingaccountabilityfornecessarycardiacprocedureswithadesignatedproviderencouragesthat
providertoensurethecarethepatientreceivesbefore,during,andaftertheprocedureisasefficient
andeffectiveaspossible.Forexample,optimalprovisionofpreventiveandcaremanagementservices
hasthepotentialtoreducetheneedforacuteeventslikeAMIandhasthepotentialtoreducetheneed
forproceduressuchasPCIandCABG.Andabundledpaymentprogramcreatesincentivesformore
appropriateuseofprocedureswhentheyarenecessary,versusthecurrentvolumebasedincentives
67
thatcanleadtooveruse.Thereareanumberofinitiativesunderwaytoaddressthegrowingcostofcare
forpatientswithCAD.WhileafewareexploringhowtoefficientlypayforCADfromthecondition
perspectiveforexample,BlueCrossBlueShieldofTexas[BlueCrossBlueShieldofTexas,2016]and
theNewYorkStateDeliverySystemReformIncentivePayment[NYSDSRIP]Program[NewYorkState,
2016]mostaredesignedtoefficientlydeliverhighqualityPCIandCABGprocedures.Theprocedure
basedmodelsinTable9aredescribedinmoredetailinAppendixE.
Table9:ExamplesofCurrentCADProcedureEpisodeModels
CABG
PCI
ArkansasPaymentImprovement
ArkansasPaymentImprovement
IncentivesProgram
IncentivesProgram
GeisingerProvenCare
GeisingerProvenCare
MedicareBundledPaymentsforCare
MedicareBPCI
Improvement(BPCI)
PROMETHEUSPayment
OhioHealthTransformation
WashingtonStateBreeCollaborative
PROMETHEUSPayment
TennesseeHealthCareImprovement
InnovationsInitiative
TheCADepisodedescribedinthispapercombinesconditionlevelmanagementwithanestedbundle
forthepaymentofaprocedure,ifoneisdeemednecessaryandappropriate(Figure9).Thesetwo
componentswillbereferredtoasconditionandprocedureinthesubsequentrecommendations.
Thegoalofthisdesignistoprovideincentivesfor:
HighqualityCADconditioncareandmanagement;
AppropriateuseofCADprocedures;and
Coordinationamongtheallproviders,includingthosewhooverseeconditionmanagementand
thosewhoperformtheprocedure.
Giventhenumberofprocedurelevelepisodeexamplesavailable forreference(AppendixE),the
discussionpresentedbelowfocusesprimarilyontheconditionleveldesignrecommendationsandthe
issuesthatariseintheintersectionbetweenconditionmanagementandprocedureprovision.TheWork
Groupadviseslookingtoexistingprocedurelevelepisodesforspecificexamplesofhowtostructurea
procedurebundle.
TheCEPWorkGrouprecognizesthataconditionlevelbundledpaymentapproachforCADwillnotexist
inavacuum.Tightlyintegratedhealthsystems,forexample,mayalreadybeoperatingmultiplebundles
forotherconditionsandimplementingprimarycaremodelsthatrequiremanagementacrosschronic
conditions.ThesescenarioswillcertainlyaffecthowaCADepisodeisdesignedandimplemented.
Implementationinmarketsthatarelessintegratedwillsimilarlybeaffectedbyenvironmentalfactors.
TheCEPWorkGroupbelievesthisapproach,whilechallenging,balanceswhatisfeasibleand,insome
cases,alreadyinpracticetoday,withanaspirationalvisionthatcanbeadaptedtomeetfuture
innovations.Figure9depictsthesettings,providers,andgoalsthatcompriseCADcare,allofwhich
informedtheWorkGroupsdecisiontodevelopanestedepisodemodel.
68
Figure9:NestedCADEpisode
TheCADepisodemodelisdesignedto:
Achieveimprovementsinpatientoutcomesandeachpatientsexperienceofcare;
Incentivizethecardiologist/primarycareprovider(PCP)toemploylowresourcetoolssuchas
medicationandlifestylechangestomanagethepatientsconditioninordertoavoidtheneedfor
procedures;
IncentivizeappropriateuseofhighresourceproceduressuchasPCIandCABGtoensurethatother
noninvasiveoptionsareconsideredwherefeasible;
ProvideappropriatecaretoallpatientsandlimitthepotentialforwithholdingappropriateCAD
managementservicesinordertoreducetheriskofcomplicationsthatcouldcountagainstthe
episodepricefortheaccountableprovider;
IncentivizecoordinationamongthePCPand/orcardiologisttocoordinatesurgeonsandothercare
teammemberstodriveimprovedpatientoutcomeswhenproceduresarerequired;
Optimizethedeliveryofprocedureswithinthecontextofconditionmanagementtoalignincentives
acrossPCPs/cardiologistsandintensivists/surgeons;and
Motivateexpandedtransparencyofclinicalqualityinformationforbothprovidersandpatients
tofacilitatemanagementofthecondition.
Recommendations:CoronaryArteryDisease
TheCEPWorkGroupreviewedarangeofexistingepisodepaymentinitiatives(seeAppendixE).Based
ontheirexperienceandtheanalysisofcurrentinitiatives,theWorkGroupdevelopedrecommendations
ontheelementsthatreflectthedecisionsthatpayersandprovidersneedtomakepriorto
implementation.
69
Forcoronaryarterydisease,itisimportantforCEPinitiativestoincludeincentivesforongoingcondition
managementtopreventexpensiveandcomplextreatmentssuchasPCIandCABGwhenever
possible.Episodepaymentalsoensuresamorecomprehensiveanalysisoftheappropriatenessofthese
procedures.Further,manyefficienciesandimprovementsincarecanalsobeachievedthroughepisode
paymentincentivesfortheprovisionoffollowupcareassociatedwiththoseprocedures,iftheyare
needed.Therecommendationsbelowreflectthesegoals.
1. EpisodeDefinition
TheepisodeisdefinedascareforacohortofpatientswithdiagnosedCAD,
fora12monthperiodthatwillultimatelyalignwiththebenefityear
(seeEpisodeTiming).Oncealignedwiththebenefityear,theepisodewill
continueforconsecutiveperiodsof12monthsofactivecaremanagement
foraslongasapatientisunderactivemanagementforCAD.PCIand/or
CABGproceduresdeemednecessaryduringanygiven12monthepisode
periodwillalsobedeliveredwithinanepisodepaymentmodel.
TheCADepisodeproposedbytheCEPWorkGroupcombinesconditionlevelmanagementwitha
nestedprocedurebundle.ThisisanimportantdistinctionfromthemajorityofexistingCADrelated
episodepaymentmodels,whichfocussolelyonPCIorCABG.Therearetwocomponentswithinthe
nestedepisode:Theconditionepisode,whichisdefinedasa12monthperiodofactivemanagementof,
andcarefor,apatientwhoisdiagnosedwithchronicCAD,andtheprocedureepisode.
TheCADconditionepisodeincludespaymentfor12monthsofpreventivecare,diseasemanagement,
andanynecessaryproceduresandfollowupcareforthoseprocedures.RecognizingthatCADisoftena
chronic,lifelongcondition,anew12monthepisodeperiodwillbeginasthepreviousperiodends,for
aslongasthepatientisinneedofactivemanagementforCoronaryArteryDisease.Aswillbediscussed
inthenextrecommendationonEpisodeTiming,apatientsinitialentryintotheepisodemaylastfor
fewerthan12months,dependingonwhethermodelisdesignedtorollpatientsintotheepisodeatthe
beginningofthemonthorquarterfollowingdiagnosis.However,bytheirsecondyearofreceivingcare
throughthisepisode,everypatientwouldbeina12monthconditionmanagementtimeframe,
beginningatthestartoftheplanbenefityear.
ThenestedprocedureepisodeisasubbundledpaymentforthedeliveryofaCADrelatedprocedure
(PCIorCABG)withinthecourseoftheconditionepisode.ForCAD,theprocedureepisodeisdefinedas
anelectiveoremergentprocedurePCIand/orCABGfortheacutetreatmentofCAD.TheCEPWork
Grouprecommendsreviewingexistingprocedureepisodemodels,suchasthosesummarizedabovein
Table2,anddeterminingwhichonesworkbestwithintheirmarket.
Whilethegoalofthisepisodeistobeasinclusiveaspossible,itwillonlyapplytopatientswhoreceivea
CADdiagnosis.Thisdiagnosismayemergefromeitheranonemergentpresentation(e.g.,shortnessof
breaththatleadstodiagnostictestingandadiagnosisofCAD)oranemergentpresentation(e.g.,an
AMIoracutePCI).Identificationofpatientsforthisepisodeisdiscussedindetailbelow.
70
2. EpisodeTiming
The12monthconditionepisodemaycommenceatvariouspointspostdiagnosis;
theprocedureepisodebegins30dayspreprocedure
andlasts3090dayspostdischarge.
Theepisodeperiodincludes12monthsofcare,whichbythepatientssecondyearintheepisodeat
thelatestwillrunconcurrenttoanindividualscoveragebenefityear(Figure10).Itisexpectedthat
mostpatientswillcontinuetobeincludedinaCADepisodeformultipleyears,giventhechronicnature
ofthecondition.Thereareoptionsregardingatwhatpointtheconditionepisodeshouldbeginafter
CADdiagnosis.
1. BeginattheNextBenefitYear:GiventhatpatientsarediagnosedwithCADthroughouta
benefityear,oneoptionistoflagthesepatientsandincludethemintheepisodeatthe
beginningofthenextbenefityear.Thissimplifiesoperationalizationoftheepisode,including
thecollectionofqualitymeasurementdata,andreconciliationofpayments,andprovides
purchaserswithimportantinformationthatcanbeusedwhennegotiatingbenefitcontracts
withpayers.Withinthe12monthperiod,anyprocedurethatisdeemednecessary,using
establishedappropriateuseguidelines,shouldbepaidforusinganepisodepaymentmodel.The
concernthatcostlyproceduresthatmaynotbenecessaryorappropriateforthepatientwillbe
frontloadedinthetimebetweendiagnosisandthestartoftheepisodeisthedownsidetothis
design.Onestrategytomitigateunintendedconsequencesofthisdesignmaybetocreatea
resourceusemonitoringwindowofseveralmonthspriortothestartofthebenefit.
2. BeginontheFirstDayoftheNextMonth(orFirstDayofNextQuarter):Whileoperationally
morecomplex,establishingtheepisodestartingpointasthebeginningofeitherthemonthor
thequarterfollowingadiagnosiswilladdress,butnotcompletelyeliminate,concernsabout
potentialunderoroveruseofservices.Inthisoption,thepatientsfirstyearintheepisode
wouldbeonlyaslongastheremainingnumberofmonthsinthebenefityear.Inthefollowing
year,theepisodestartwouldalignwiththebenefityear,andthepatientwouldexperienceafull
12monthepisodeperiod.Thisoptioncombinesthebenefitofreducingpotentialunderorover
useofcertainservicesorprocedureswiththebenefitofadministrativeeaseinthepatients
secondyearandbeyond.
Forpayers,oneimportantfactortoconsiderwhendesigningtheepisodestartisthemethodby
whichpatientsettlementandreconciliationisprocessed.Aprocessinwhichepisodesaresettledon
acasebycasebasiswillaccommodategreaterflexibilityandallowpatientstobemovedintoan
episodicincentiveinitiativeonarollingbasis.Ifapayersettlesepisodesbasedonaveragesovera
performanceperiod,theremaybelessroomforflexibilityinthestartingpoint.
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Figure10:CADEpisodeTimeline
IntheeventofPCIorCABG,thestartoftheepisodedependsonwhetheritisacuteornonacute.Ifitis
anelectivePCI,theepisodebeginswitha30daypreoperativeperiod.Theinclusionofapreoperative
periodwillsupportcoordinationacrossthemultipleprovidersinapatientscareteamandserveto
reduceunnecessaryresourceutilizationleadinguptotheprocedure.Ofcourse,CADproceduresarenot
alwayselective;inthecaseofanemergencyprocedureofeitherPCIorCABG,theepisodebeginswhen
itisdeterminedthataprocedureisnecessaryandappropriate.Thatmayoccurassoonas24hoursprior
totheprocedure.
TheWorkGroupdidnotdeveloprecommendationsforthelengthoftheprocedureepisode.Therearea
numberofexistingPCIandCABGmodels(Figure10)towhichreaderscanrefertoweighthebenefitsof
extendingtheprocedureepisodeto30,60,or90dayspostdischarge.Itmayalsobeusefultobuildina
30daylookbackperiodfromdiagnosestocapturethecostsoftheworkuptoobtainthediagnosis.The
longertheprocedureepisode,themorepostacuteserviceswillbeincluded.Theconditionepisodewill
runconcurrentlywiththeprocedureepisode.Inotherwords,the12monthconditiontimeperiodwill
notpausewhileapatientisexperiencingaprocedure.Thisisdeliberate,toincentivizeseamless
transitionsbetweeneachstepinthecarecycle:Conditionmanagement,surgicalprocedure,
hospitalization,discharge,postacutecare,andagain,conditionmanagement.However,ifaprocedure
isnecessaryandthepatienthasnotyetbeendiagnosedwithCAD(soitisnotpartofthecondition
basedCADepisode),theprocedurebaseddefinitionswillapply,andtheconditionlevelepisodewill
commenceineitherthenextmonth,quarterorbenefityeardependingonthedesignofthemodel.
3. PatientPopulation
Condition:PatientsdiagnosedwithCADandinsamehealthplan
forfull12months.
Procedure:PatientsdeemedtoneedaPCIorCABGbased
ondeterminationofappropriateness.
72
Thepopulationofpatientswhocouldparticipateintheconditionepisodeisbroadandincludesall
patientsflaggedbyaproviderasdiagnosedandunderactivemanagementforCAD.Individualswho
disenrollfromtheirhealthplanpriortotheendofthe12monthepisodeperiodwillberemovedfrom
theepisodepopulation.
Healthplansshouldanalyzeclaimsfromatleasttheprevious12monthstoasfarbackas24monthsin
ordertoidentifyallpatientswhofitthispopulationdefinition.Thegoalofthisepisodemodelisto
improvethevalueofcaredeliveredtohighneedpatients.TheWorkGrouprecognizesthatfor
individualswhohavebeenlivingwithCADformanyyears,activemanagementtendstoevolveintoan
annualvisittotheproviderforongoingmedicationmanagement.Whilethesepatientscanbeincluded
intheepisode,doingsomaynotaddadditionalvalue.Establishingaminimumnumberofvisitsorclaims
tobeeligibleforinclusioninanepisodepaymentcouldbeonewaytoaddresspatientswithlimited
ongoingneededCADmanagement.Thiscouldalsostrengthenthedeliveryofcarereceivedthrough
primarycaremodels.AnimportantissueforpayersandproviderstoexaminewhendesigningaCAD
conditionepisodemodelishowtoaddressthevariationinCADseverityacrossapatientpopulation.
OnewaytoaddressthisistoestablishpatientcohortsdefinedbywhetherapatientsCADisstableor
unstable,orbywhethertheyrequiremedical,surgical,orpercutaneoustreatment.
ThepopulationfortheprocedureepisodecomprisespatientswhoaredeemedinneedofaPCIorCABG
procedureinordertomanagetheirCAD.ProvidersshouldusesuchtoolsastheAppropriateUseCriteria
forCoronaryRevascularizationGuidelines13and/ortheappropriatenessguidelinesdevelopedbythe
SocietyofThoracicSurgeons(STS)todeterminewhetherapatientshouldundergoanonacute
procedure(Patel,2012;AmericanAssociationforThoracicSurgery,2016).
Inadditiontoappropriateusecriteriaandguidelines,othermodelsexistfordeterminingtogetherwith
apatientwhetheraprocedureisappropriate.OneexampleistheHeartTeam14approach,created
foruseintheTransCatheterAorticValveReplacementProgram.Forpatientsinthisprogram,aHeart
Teamconsistsofavarietyofcliniciansincluding,butnotlimitedto,acardiologistand/orprimarycare
provider,cardiothoracicsurgeon,cardiacanesthesiologist,andhospitalist.TheHeartTeamservesto
reviewcasesinwhichapatientisreferredforinvasiveCADtreatmentbyassessingpatientdata,
consultingwiththepatientandfamily,anddiscussingbestoptionsforcare.Thismodelwouldrequire
considerationofappropriatereimbursementwithintheepisodepriceifincludedinanepisodedesign.
13
TheAppropriateUseCriteriaGuidelinesweredevelopedbyaconsortiumthatincludestheAmericanCollegeof
CardiologyFoundation,theSocietyforCardiovascularAngiographyandInterventions,theSocietyofThoracic
Surgeons,theAmericanAssociationforThoracicSurgery,theAmericanHeartAssociation,theAmericanSocietyof
NuclearCardiology,andtheSocietyofCardiovascularComputedTomography.
14
SocietyforCardiovascularAngiographyandInterventions,TheRevascularizationHeartTeam:TakePatient
CenteredCaretoHeart,August26,2014,http://www.scai.org/QITTip.aspx?cid=e7ec55bc8e924fcd8b4d
4cb73bd8af5b
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4. Services
Forboththeconditionandprocedureepisodes,theservicesshould
includecoreservicesforCADmanagement(e.g.,lifestylechanges,
medicationmanagement,andsecondaryprevention);andcoreservices
forthequalitydeliveryofaprocedure(e.g.,preoperativediagnostics,
drugsanddevices,caretransitionsupport,and
postacutecareincludingcardiacrehab).
ThegoaloftheepisodepaymentforCADistoensurethatpatientsreceiveallappropriateservices
neededtoimprovetheirqualityoflife,managetheirCAD,andpreventtheneedforproceduresand/or
preventpoorhealthoutcomessuchasAMIorheartfailure,whileavoidinginappropriateservices.To
achievethis,theepisodeservicesshouldstriveforinclusivityandcomprisethefollowingcoreservices,
manyofwhichfallintothecategoryofsecondarypreventionforpatientswhoarediagnosedwithCAD
followinganacuteoremergencyevent:
OverallManagement:Servicesshouldincludeappropriatediagnostics,sharedcareplanning,and
coordinationofservicesacrossvarioussettingsandproviders.
MedicationManagement:CADpatientsareoftenputonalongtermmedicationregimentocontrol
CADsymptoms.Thesemedicationsmayincludeaspirin,betablockers,anginacontrolmedication,ACE
inhibitorspostAMI,andlipidmanagementmedications.Ensuringthatmedicationistaken
appropriately,managingmedicationsideeffectsandpooroutcomesduetocontraindicationsfrom
othermedications,isakeypartofCADconditionmanagementcare.
LifestyleSupportRelatedtoModifiableRiskFactors:Thereareanumberofriskfactorscorrelatedwith
CAD,includinghighbloodpressure,smokingandtobaccouse,diabetes,stress,andweight.ClinicalCAD
managementshouldincludeservicesdesignedtosupportlifestylechangesthataddresstheserisk
factors.Servicestosupportweightloss,stressreduction,smokingandtobaccocessation,anddiabetes
controlarecriticaltoCADmanagement.
ServicesSpecifictoPCIandCABG:Theconditionepisodeandtheprocedureepisodeshouldincludeall
preoperativediagnosticsandcareplanning,drugsanddevicesrelatedtotheprocedure,discharge
planning,caretransitionsupport,andpostacutecare,includingcardiacrehab.Itisextremelyimportant
toincludecardiacrehabintheprocedurebundle,giventhatfewer than20percentofpatientseligible
forthiscaregoontoparticipateinacardiacrehabilitationprogram.RefertoresourcesinAppendixH
formoreinformationonspecificservicesincludedinPCIandCABGepisodepaymentmodels.Oneissue
toconsideriswhetherapatientwhoreceivesaconcomitantproceduresuchasavalvereplacement
duringthecourseofaCABGshouldbeincludedinthenestedprocedureepisode.Examplesofhow
CABGepisodepaymenthasbeendesignedandimplementedwillprovideguidanceonquestionsrelated
towhatservicesandpotentialconcomitantproceduresshouldbeconsideredwithinthescopeofthe
CADprocedureepisodemodel.
Forbothconditionandprocedureepisodes,thepaymentmodelwillrelyonstrategicallyselectedquality
measurestoholdprovidersaccountablefordeliveringappropriatecare.Thetypesofservicesdescribed
74
abovearealsoservicesthatareprovidedbyprimarycareproviders.Itwillbecriticalforthosethat
managetheseepisodestocoordinatewith,andbuildupon,thecarethatisalreadybeingprovidedina
primarycarecontext.Thiswillbeparticularlyimportantifotherpaymentreforms,suchasPatient
CenteredMedicalHomes(PCMH),areinplacebecausethosepracticeswillalsohaveaccountabilityfor
thecostsandqualityofcareforthatpatientlivingwithCAD.TheboxatrightdescribesComprehensive
PrimaryCarePlus(CPC+),oneprominentupcomingprimarycarerelatedinitiative.
AchallengeindefiningthecoreservicesforCAD
isthefactthatpatientswithCADoftenhave
comorbiditiessuchasdiabetes,hypertension,
kidneydisease,obesity,andperipheralvascular
disease.Whileacardiologistisnotgoingto
manageapatientschronickidneydiseasecare,
heorshemayhaveaninterestinworkingwith
thepatienttomanagetheirdiabetesorweight,
sincebothwillhaveanimpactontheefficacyof
theirCADcare.Thequestionofwhatservicesto
include,andwhethertheyarecodedforCAD
care,diabetescare,orothercomorbidities
associatedwithCADwillneedtobeaddressed
formultiplereasons.Determiningthelistof
servicestoincludewillhaveadirectbearingon
thelevelatwhichtheepisodepriceisset,and
determininghowtocodeservicesthatare
relevanttocareforCADanditscomorbidities
willhaveadirectbearingonwhetheraprovider
isdeterminedtohavecomeunder,over,orhit
theepisodepricetargetatthecompletionofthe
episode.Forexample,thereisthepotentialfor
codinglifestylechangesupportservicestothe
diabetesconditioninsteadofattributingthat
spendingtotheCADepisodeifaprovideris
participatingintheCADepisodebutnotasimilar
episodefordiabetes.
TheComprehensivePrimaryCarePlus(CPC+)
InitiativeandCADEpisodePayment
TheCenterforMedicareandMedicaid
Innovation(CMMI)recentlyannouncedthe
ComprehensivePrimaryCarePlus(CPC+)
initiativetosupportthedeliveryofcarevia
advancedprimarycaremedicalhomes.TheCPC+
initiativebuildsonthefoundationofthe
ComprehensivePrimaryCare(CPC)initiative,
whichconcludesinDecember2016.
ThehallmarkoftheCPC+initiativeisitsmulti
payerpaymentredesignfocus,whichwillinvolve
coordinationacrossCMS,commercialinsurance
plans,andstateMedicaidagenciestosupport
primarycarepracticesinmakingsignificantand
fundamentalchangesinhowcaredelivery
occurs,toachievethegoalsof1)accessand
continuity,2)caremanagement,3)
comprehensivenessandcoordination,4)patient
andcaregiverengagement,and5)plannedcare
andpopulationhealth.
Giventherolethatprimarycareprovidersplayin
thecaremanagementofpatientswithCAD,itis
possiblethatCPC+initiativeparticipantsmayalso
considerimplementationofthisCADepisode
model.Itwillbeimportanttoconsiderthe
implicationsoftheCPC+initiativeontheepisode
designandimplementationaspartofthedesign
process.
Onestrategyfordeterminingcoreservicesisto
includethosewithaCADrelateddiagnosiscode.
ServicesthatwilladdressneedsrelevanttoCAD
andothercomorbiditiesshouldbeincluded.Itis
alsopossiblethatthiswillnotbeanissuefor
primarycareproviderswhoareworkingwithina
systemthatoperatesmultipleepisodepaymentmodels.Ultimately,whethertheimplementing
organizationseekstodevelopadiscreteCADepisodemodel(i.e.morenarrowlydefinedservice
inclusions)orifithasalreadyestablishedotherepisodepaymentmodelsthatitwantstobuildupon(i.e.
broadersetofserviceinclusions)willdeterminehowbroadtheserviceinclusionswillbeinthisepisode.
75
5. PatientEngagement
Modelsshouldsupportpatientandfamilyinvolvementinepisodepayment
design,implementationandevaluation;aswellaspatientandfamilyengagement
inallphasesofcardiaccare,facilitatedbyHealthInformationTechnology.
Personcenteredepisodepaymentmodelshaveastronginvestmentinengagingpatientsinmultiple
ways,includingthroughsharedcareplanning,shareddecisionmaking,comparativequalityinformation,
carecoordination,chronicdiseasemanagementtools,transparencyofpaymentinformation,andcare
transitionsupport.Examplesofthetypesofprocessesandtoolsdescribedinthissection arein
AppendixH.Tobeeffective,communicationsandresourcesmustbetailoredtothehealthliteracylevel
ofpatientsandfamiliesandlinguisticallyandculturallyappropriate.
Supported,SharedCarePlanning:Providersshouldincorporatesharedcareplanningearlyinthe
deliveryofcare.Thisprocessshouldincludecollaborativeproviderpatientgoalsettingrelatedtoboth
thecareforCADasaconditionandanygoalsettingrelatedtoaPCIorCABGprocedure.Sharedcare
planningalsoinvolvesongoingdecisionmakingandmonitoring,usingdocumentedindividualizedcare
plansthatareaccessibletothepatient,families,andproviders.
SharedDecisionMaking:Overthecourseofconditionmanagement,apatienttogetherwithafamily
caregiverideallymusthavetheopportunitytoengageinshareddecisionmakingduring1)theprocess
ofdevelopingacareplanthatsupportsthepatientsgoals,values,andpreferences,includinghowbest
tomanagetheirconditionthroughmedicationandlifestyleapproaches;and2)determiningwhetherto
undergoaPCIorCABGprocedure.However,theshareddecisionmakingprocesscannotbeacheckthe
boxactivity.Thereneedstobeevidencethatthepatientandfamilycaregiverweresupportedbya
decisioncoachoranurseeducatorastheyworkedwithadecisionaidthatmeetsathresholdscore
usingtheInternationalPatientDecisionAidsStandards(IPDAS).
ComparativeQualityInformation:Patientsandfamilycaregiversmustbeprovidedwithinformation
abouttheprocedurecomplicationratesandqualityofpossiblesurgeonsandpossibleacutecare
facilities.Clearlydesignatedpersonnelwithoutconflictsofinterestshouldassistpatientswith
identifyingeligibleprovidersandinfindingandinterpretingrelevantinformationaboutthoseproviders.
Transparencyofqualityinformationmayalsoallowthepatienttogetherwiththeproviderand
familytomakeinformeddecisionsontheinclusionofcertainprovidersonthecareteam.
CoordinationAcrossProviderSettings:Carecoordinationtakesvariousforms,includingthefollowing:
PatientCenteredTransitionalCareServices:TheCADmodeldescribedhereinisdesignedtosetup
tightcaretransitionlinkagesbetweentheprovidersoverseeingapatientsprocedureandthose
overseeingapatientsoverallCADcaremanagement,andthepatientsprimarycareproviders.
Withinthiscarecoordination,however,istheoftenchallengingaspectofcareknownascare
transition.Followingdischargefromahospital,49%ofpatientexperienceatleastoneerrorin
medicationcontinuity,diagnosticworkup,and/ortestfollowup,19%to23%ofpatientssufferan
adversedrugevent,andin75%ofcases,dischargesummariesforapatientdonotarriveatthe
physiciansofficeintimeforthefollowupappointment(Tsilimingras&Bates,2008).ACADepisode
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modelneedstoengagepatientsintransitionalcareservicestobesuccessful.Duringthetransitional
time,providersmustcommunicatewitheachother,familycaregiversmustbeengagedandinvolved
inpostacutecareplanning,andpatientsmustbegivenclearinformationonhowtomanagetheir
condition.Thefollowingprogramsreflectanumberofdifferenttoolsandmodelsfortransitional
care:
TheAcuteCareforElders(ACE)programstartsdischargeplanningatthetimeofadmissiontothe
hospital.
TheCareTransitionsCoachingprogramattheUniversityofColoradousesatransitioncoachto
teachpatientsandcaregiversskillsthat
promoteandsupportcontinuityofcare,
DeployingMeaningfulSharedDecisionMaking
bothinthehospitalandfor30dayspost
forPatientsandCaregivers
discharge.
Requiringproviderstouseshareddecision
TheAmericanCollegeofCardiologyand
makingtoolsdoesnotnecessarilytranslateinto
theInstituteforHealthcare
meaningfulshareddecisionmakingprocess
ImprovementsH2HHospitaltoHome
betweenapatientwithhisorherfamily
QualityInitiativefocusesonpost
caregiversandproviders.Inordertomakethe
dischargemedicationmanagement.This
shareddecisionmakingprocessonethattruly
ensuresthepatienthassymptom
supportspatientengagementanddrivesthe
managementandarapidfollowup
appropriateuseofproceduresandothercare,
appointmentwiththeircardiologistor
providerandpatientprocesseswillincludethe
primarycareprovidertoensurethatthe
following:
patientfullyunderstandsthesignsand
Acknowledgethatthereisadecisiontobe
symptomsthatrequiremedicalattention.
made;
Itisalsoimportanttodiscusstheoptionsof
Explainthattherearecareoptions,andeach
inoroutofnetworkpostacuteorfollowup
optionhasadifferentsetofissuesto
carewithpatientsandfamilycaregivers.In
consider;
theMedicareFFSprogram,thismayinvolve
Presentthebestevidenceabouttheprosand
discussionsrelatedtochoiceofpostacute
consofthecareoptions;and
providers,confirmingthatthepatientsstill
Acknowledgehowpersonalvaluesand
havefreedomofchoice.Thisisacritical
preferencesmightalignwiththecare
patientconversationbecauseapatientmay
options.
notwishtoseeaproviderthatiswithina
specifiedpaymentarrangement.
Followinganopportunityforthepatientand
familycaregivertomeetwithadecisioncoachor
anurseeducatortoreviewdecisiontoolsandget
answerstoanyquestions,theyshoulddetermine
togetherwithacareprovidertheoptimalpath
forward.
ChronicDiseaseManagementTools:Thegoal
ofconditionmanagementcareistwofold.
First,itistohelppatientsmakethekindof
lifestylechangesthatwillpreventaggravation
oftheirdiseaseortheneedforaprocedure.
Second,itistomanageapatientsmedication
protocol.Patientengagementiscriticalinbothareasandrequireswelldesignededucationalmaterials
andtoolssuchasinpersoncoaching,smartphoneappsfortrackingadherencetolifestylechange
activities,andpatientsupportgroupstoprovidebothemotionalsupportandtipsandtricksfromothers
whohaveexperiencedsimilarconcernstopatientsdiagnosedwithCAD.Whenavailable,highquality
decisionaidsshouldbeusedtomakecaremanagementdecisions.Astudytotracktheeffectsof
smartphoneappusagewasconductedbytheMayoClinicandfollowed44patientsparticipatingin
77
cardiacrehabfollowingaheartattackandPCI.Patientsweredividedintotwogroups:onethatusedan
apptorecordtheirweightandbloodpressuredailyinasmartphone,andonethatdidnotusetheapp.
Theappgroupexperiencedgreaterimprovementsinthosecardiovascularriskfactors,andwasless
likelytobereadmittedtothehospitalwithin90daysofdischarge,comparedtothenonappgroup.The
appgroupalsoreceivededucationalactivitiesthatsupportedlifestylebehaviorchanges.Thegoalofthe
appandthestudywastobothdemonstratetheefficacyofcardiacrehabonpostAMIandPCIrecovery,
andtheimportanceofengagingpatientsinowningtheirlifestylebehaviorchanges(Klein,2014).
TransparencyofReimbursementandPaymentFlow:Patientsandfamilycaregiversneedtransparent
informationonhowprovidersarebeingreimbursedinanepisodepaymentmodel,theimpactthat
episodepaymentmayhaveonthepatientscostsharingorcopayresponsibilities,andthemannerin
whichcarewillbedelivered.
SMARTCarePilot:TheFloridaandWisconsinchaptersoftheAmericanCollegeofCardiologydeveloped
thispilotprojecttoimprovequalityofcare,enhanceaccesstocare,andreducehealthcarecostsby
providingtoolstohelpphysiciansandcardiovascularteammembersapplyguidelinesandappropriate
usecriteriaatthepointofcare.ThepilotinvolvesembeddingSMARTCaretoolsincludingpatient
educationandshareddecisionwithineverystepalongtheCADcarepathway.SMARTCareisalso
designedtoprovidepatientsandphysicianswithaccesstodataonclinicalqualitymeasures,outcomes,
andresourceutilization.AmongthetoolsincludedintheSMARTCareprogramarethePROMs(TONIC,
SAQ7,HeartQualityofLifeandDecisionQualityAssessmentInstrument.
Patientsshouldbeinvolvedwithallaspectsofidentifyingandachievingcaregoalsandshouldactively
participateintheircareplanning.Theyshouldalsobeencouragedtoengagetheirprimarycareprovider
intheirdecisionmakingprocess,especiallythosepatientswithchronicdisease.Integrationofhealth
informationtechnologythatfacilitatesaccesstohealthdata,sharedcareplans,educationalandsupport
tools,andcommunicationswithmembersofthecareteamcanimprovethetopicsdiscussedinallofthe
abovesections.OneexampleofatoolthatisprovidingaccesstothesedataisthesuccessfulOpen
Notesproject,whichisprovidingagrowingproportionofpatientstofullaccesstotheirelectronic
healthrecords(Belletal.,2015;Eschetal.,2016;Walker,Meltsner,&Delbanco,2015).HITisalso
crucialfortimelyfillingofprescriptions,makingnecessaryappointments,communicatingwithmembers
ofthecareteambetweenvisits,andcompletingpatientreportedmeasuresurveys.
6. AccountableEntity
whatentityorentitiesshouldbeaccountable.Thereareanumberofkeyrequirementsneededfor
successregardlessofwhichentity(orentities)areheldaccountable.Payersshouldworkwiththe
78
accountableentitytoassesstheirreadiness,andpromotecollaborationtoallowformultipleproviders
withinaCADcareteamtosharetheriskandrewardinsuchamannerthatallareengagedincreatinga
seamless,efficient,patientcenteredcareprocess.Thisprocesscanrequireactiveparticipationacross
thecontinuumbyaligningincentivesacrosscontractsintheprivatesector,becausethepayeroftenhas
contractsdirectlywithproviders.MedicareallowsforfullfreedomofchoiceofproviderinFFS,andthe
riskspreadingmaytaketheformofagainsharingrelationshiponceaMedicarewaiverisinplace.Thisis
particularlyimportantinarelationshipwherebytheprovidersarestillpaidFFSwitharetrospective
reconciliation,becausetheaccountableentityhaslimitedabilitytoobtainbuyinfromotherproviders
intheepisodewithoutdirectincentivesforthemtocollaborate.
FactorstoWeighinDeterminingReadinessforEpisodeAccountability:
Minimumvolumestandards,inacuteandpostacutecare,fortheCADpatientpopulation;
Abilitytodeliver,orcontractfor,theentirebundleofservicestoberendered;
DemonstratedabilitytocareforCADpatients;
Effectivedischargeplanningcapacities,includingsystemstoincluderehabilitationphysiciansand
extendersearlyinthedischargeplanningprocesstohelpinidentifyingthepropertrajectoryof
patientsandtheircare;
Abilitytomanagetransitionsorhandoffsfromonesettingtoanotherwhennecessary(e.g.entry,
transitions,anddischarge);
Abilitytotrackqualityindicatorsandpatientoutcomesacrossanarrayofservicesandsettings;
Demonstrateddedicationofthehospital,physicians,nurses,therapists,andotherclinical
professionalstimetotheprograms;
Capacitytomonitorpatientclinicalstatusandcoordinatemedicationmanagement/reconciliationas
patientsprogressacrossacuteandpostacutecaresettings;
Abilitytocoordinatewithothercommunityservicestofosterthepatientsindependence;
Necessaryfinancialsystemstoadministerpaymentacrossmultipleentities;and
Abilitytotoleratefinancialrisk,includingpostdischargeoutcomes,suchasreadmissions,and
understanditsownriskexposure.
Therewillneedtobeaccountabilityplacedontheclinician(s)whooverseeboththecondition
managementandthePCIorCABGproceduresinsituationswhereeitherprocedureisneeded.Shared
accountabilityisanimportantdesignideatoconsider,especiallygiventheimportanceofateambased
approachtothismodel.Underthissharedaccountabilityumbrella,payerscannegotiatewithproviders
andusegainandlosssharingtoenableasysteminwhichallproviderswhotouchthepatientshare
somelevelofaccountability.Payerswillneedtoassesswhichprovider(s)inagivenmarketcanactmost
effectivelyinachievingaCADepisodepaymentinitiativesgoalsandestablishthatproviderorproviders
astheaccountableentity.
Insomeinstances,thecareteammaybenarrower,particularlyifoneclinicianorclinicianorganizationis
abletoprovideboththeconditionmanagementcareandconducttheprocedure.Thismaybethecase
ifthecardiologypracticealsoincludescardiacsurgeonsorifthepatientisseenwithinahealthsystem
thatintegratesbothhospitalandoutpatientservices.Amorecommonscenarioiswhenaprimarycare
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providerorcardiologistismanagingtheCADbeforetheneedforaprocedureisdeemednecessaryanda
separatepracticeisidentifiedtomanagethepatientsprocedure.
TheaccountableentitiesincurrentexamplesofCADepisodepaymentvary.Becausecurrentmodelsare
typicallyprocedurebased,itisoftenthehospitalthatservesastheaccountableentity.Sometimes,itis
thephysicianpractice(oftenthecardiologypractice).Inmanycases,theclinician,whenactingasthe
accountableentity,canhavethegreatestimpactoncareredesignbecauseestablishingaphysicianlevel
quarterbackcaneasetheepisodesmanagementprocess.Thecliniciancanleadthedesignand
implementationofnewpatientcareprotocols,andcommunicatewiththepatientspostdischarge
providermoreeasilythanthehospital.Further,discussionswithpatientsregardingappropriatenessand
expectationsonfunctionalimprovementsaremosteffectiveifthephysiciansarefullyengaged.
IntheAcuteCareEpisode(ACE)demonstrationthehospitalservedastheaccountableentity,whichis
consistentwiththeepisodedefinitionasitislimitedtohospitalandphysiciancaredeliveredinthe
hospitalforcertaincardiothoracicprocedures(CentersforMedicare&MedicaidServices,2016).The
rulesallowedthehospitaltoopttoshareaportionofgainsorlosseswithotherprovidersthatarepart
ofthedeliveryofcareforpatients,includingphysiciansorotherpostacuteproviders.Whilethehospital
wastheaccountableentity,itwasconsideredcriticaltogetthephysiciansinvolved.Thehospitalsinthat
initiativeutilizedgainsharingtoengagethephysicians.Theaccountableentityinthemorerecent
BundledPaymentforCareImprovementdemonstration,whichincludedcardiaccaresuchasCABG,PCI,
orAMI,couldbeaphysicianpractice,hospital,healthsystem,orasocalledconvenerthatwould
organizetheeffortacrossmultiplesites.Premier,whichisanorganizationthatworkswithhospitals,and
Cogent,whichmanageshospitalistpractices,aretwoexamplesofsuch.Itisnotsurprisingthatthe
accountableentitieswereoftenhospitalsinasmuchasthisbundledpaymentprogramwasalsocentered
uponproceduresdeliveredinthehospitalalbeitsomewhatbroaderinseveralmodels(Centersfor
Medicare&MedicaidServices,2016a).
AbilitytoAcceptRisk:Abilityandreadinesstoacceptriskarehighprioritiesamongthefactorsthat
shouldbeusedtodeterminetheaccountableentityorentities.Somephysicianpracticesmayhaveless
abilitytoassumedownsideriskthanlargerpracticesorotherbettercapitalizedproviders,suchas
hospitalsorhealthsystemsthatintegratehospitalandphysiciancare.Limitingthelevelofrisk
associatedwiththeepisodecanmitigatethislimitedabilityforphysicianpracticestotakeonrisk.
Recommendation7,PaymentFlowdiscussessomestrategiesfordoingthis.
Insituationswheresharedaccountabilityisnotfeasible,otherscenariosmightincludeonemulti
specialtygroupholdingaccountabilityforboththeconditionandtheprocedure,usinginternal
mechanismsforoperationalizingjointaccountability,oracardiologypracticeholdingaccountabilityfor
theentireconditionepisode,andaspartofthisaccountability,coordinatingwithasurgicalpracticeifa
procedureisdeemednecessary.Again,transparent,accessiblequalityinformationwillhelpthe
accountableentityseekoutthehighestperformingproceduralists.Thecommonalitiesofthesenotional
scenariosarethattheaccountableentityisincentivizedtoensurethecareintheprocedure(ifneeded)
isasefficientaspossible,thatthehandoffspreandpostprocedureareassmoothaspossibleforthe
patient,andthattheclinicianaccountableforthefullepisodeseekstocontractwiththehighest
performingproceduralists.
SeethechapteronOperationalConsiderationsforadiscussionontwo related issues:First,in thedata
infrastructuresectionisadiscussionofthestructuresnecessarytofacilitatecoordinationand
communicationacrossmembersofthecareteamandbetweencliniciansandpatients.Second,inthe
regulatoryenvironmentsection,isthediscussionofhowstatelawsmayaffecthowmuchriskproviders
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areallowedtoincur.Forexample,somestateslawsandregulationsaresupportiveofhospitalstoserve
astheaccountableentity,ratherthanaphysicianorphysicianpractice.
7. PaymentFlow
Theuniquecircumstancesoftheconditionlevel/nestedprocedure
episodemodelmakesupfrontFFSpaymenttoindividualproviders
withintheepisode,withretrospectivereconciliationandpotential
forsharedsavings/risk,themorefeasibleoption.
(Figure11).
InProspectivePayment,paymentisprovidedforthewholeepisode,includingallservicesand
providers,andpaidtotheaccountableentity,whichsubsequentlypayseachproviderinturn.This
paymenttypicallyoccursaftertheepisodehasoccurred,butistermedprospectivebecausetheprice
oftheepisodeissetinaprospectivebudgetaheadoftime.Thesavingsorlossesarenotsharedwiththe
payer;theyaresimplyafunctionofhowwelltheaccountableentityandtheproviderswithwhomit
coordinatesaremanagingthepredeterminedprice.
InRetrospectiveReconciliation,individualprovidersareeachpaidonatypicalFFSbasisandthenthe
targetepisodepriceandtheactualaverageepisodepricearereconciledafteraperiodoftimeacrossall
theepisodesattributedtoaprovider.Aninitialreconciliationistypicallyconductedbytheendofthe
firstquarterafteranepisodesend,andafinalreconciliationistypicallyconductedwithinsixmonthsof
theepisodescompletion.ForthisCADepisode,thesereconciliationstakeplaceinroughlyApriland
June.Basedonaspecificformula,eithernegotiatedordeterminedbythepayer,theaccountableentity
cansharewiththepayeringainsand/orlosses.Gainsorlossesarealsosharedamongprovidersinthe
episodetoencouragecollaborationandcoordinationacrosssettingsinsomeinstances.Thesetypesof
gainsharingarrangementsneedtobeconsideredwithintheconstraintsoffederallawsthatmayimpact
theirdesign,whichisdiscussedinfurtherdetailintheregulatoryinfrastructuresectionofChapter6,
OperationalConsiderations.
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Whileprospectivepaymentisanoptioninsomecircumstances,suchaswhentheaccountableentityisa
healthsystemthatalreadyintegratestheclinicianandfacilitypayment,theWorkGrouprecommends
usingretrospectivereconciliationforthisepisodemodel.Retrospectivereconciliationissimplerto
administer,andrequiresfewerchangesfromcurrentpracticewheretheprevailingmodelisanopen,
nonintegratedsystem.Inaddition,retrospectivereconciliationismoreprevalentincurrentepisode
initiativesbecauseitdoesnotrequireproviderstodevelopthecapacitytopayclaims,itallowsfor
bettertrackingoftheresourcesusedintheepisode,anditcanbebuiltonanexistingpaymentsystem.
Retrospectivereconciliationmayalsocontinuetoengagethepayerasapartnerastheymaintainamore
directinterestinthefinancialsuccessoftheprogram.
Itmaybemoredifficulttoimplementasingleprospectivepaymentwhenmultipleprovidersinvolvedin
deliveringthecaredonotalreadyhavemechanismsforadministeringpaymentamongthemselves,
whichisthecaseinintegratedsystems.However,prospectivepaymentmayalsobebetterat
encouraginginnovationasprovidersinaprospectivepaymentprogramareoftennotlimitedbythe
payerscoveragepolicy.Increaseduseofprospectivepaymentcanacceleratedevelopmentofvarious
supportingmechanismstoaidinthisprocess.OnecautiononprospectivepaymentinaFFSMedicaid
programisthattheremayberegulatorybarriersforoneproviderassigningpaymenttoanother.Legal
counselshouldbesoughtinthisscenario.
AnadditionalconsiderationinthisCADepisodepaymentapproachiswhethertheaccountableentityis
thesameforboththeconditionandtheprocedure.Ifthepaymentflowisretrospectivereconciliationof
FFSpayments,andtheaccountableentitiesarebothexpectingtoshareingainsorlosses,themannerin
whichthosegainsorlossesaresplitwithinthetimeperiodoftheprocedureepisodeswillbeacritical
issue.
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8. EpisodePrice
Theepisodepriceshouldstrikeabalancebetweenproviderspecificand
multiprovider/regionalutilizationhistory.Thepriceshould
2) reflectalevelthatpotentialproviderparticipantsseeasfeasibletoattain;
and3)includethecostofservicesthathelpachievethegoalsofepisodepayment.
Pricingepisodesissignificantlycomplexasaresultoftheneedtobothassuretheaccuracyofestimates
anddevelopapricingstructurethatisfairtoprovidersbutencouragesinnovation.Thegoalshouldbeto
establishapricethatencouragescompetitionamongproviderstoachievethebestoutcomesatthe
lowestcost.Issuessuchasaccountingforvariationintheriskofthepopulation,havingalargeenough
patientpopulationtoallowforsufficientvariation,theimpactofdifferingfeeschedulesandnegotiating
power,shiftsininsurersmidstream,regionalvariationinavailabilityoftypesofproviders,andensuring
thatpaymentsaresufficienttoadequatelyreimburseforhighvalueserviceswillallneedtobetaken
intoconsideration.Forexample,Recommendation3,PatientPopulation,describestheimportanceof
usingamodelsuchastheHeartTeamtohelpmakeappropriatedeterminations.Incorporatingthis
model,whichisnotcurrentlyusedundertraditionalFFSreimbursement,willrequirecalculatingthe
reimbursementcoststodothiswork.
Itwillalsobenecessarytoidentifyapricethatbothreflectscurrentutilizationpracticesandcreatesan
achievablestretchgoal.Factorssuchasdecreasedratesofuseofcertaintesting,procedures,orlower
complicationandreadmissionratesmayaffecttheepisodepriceasaresultofthis.Inessencethisbakes
inacertainlevelofdownsiderisk,buttheproviderknowsupfrontthetargettheymustreach.However,
theepisodepriceshouldnotbesetsolowthatprovidersarediscouragedfromdeliveringallnecessary
care.
Themannerinwhichtheepisodepriceisestablishedlargelydeterminesthemonetaryrewardsor
penaltiesthatanaccountableentitymayexperience.Severalkeyaspectsinteractinthedetermination
oftheepisodeprice.Allpayerswillexpectsomereturnontheirinvestmentsinthispaymentdesignand
canchooseavarietyofmechanismstogeneratesomelevelofsavings.Itisalsoimportanttoconsider
includingcostsfortheservicesdescribedinRecommendation5,PatientEngagement,inthetarget
episodepriceinordertoprovidesufficientresourcesforcarecoordination,caretransitions,shared
decisionmaking,andotherstrategies.
BalancingRegionalandProviderSpecificData:Costdatashouldreflectamixofproviderandregional
claimsexperience.Thegoalofincludingregional,ratherthanmarketleveldata,istoensurethatthereis
enoughvariationinepisodecost.Thismixwillalsoensurethattheestablishedepisodepricetakesinto
considerationtheuniqueexperienceofthespecificprovider,andthatthegoalsaresetbasedonwhatis
feasibleintheregion.Riskadjustmentwillbeneededduringthisprocesstoadjustfortheunique
characteristicsofthepopulationtheproviderserves.Ifthepayerisanationalpayer,itmaybemore
difficulttoaddressspecificproviderissuesandwillrequireconsiderationoftheuseofnationalclaims
experiencetoensureequityacrossregions.Overtime,asperformancebecomeslessvariable,itmaybe
usefultolessentheproportionoftheepisodelookbackperiodthatisbasedontheorganizations
83
specificexperience.Thepayercanalsoincludeanestimateofadecreaseincostsbasedon
improvementsinsomecases,suchaslowerrateofPCIorCABG,orreducedrateofhospital
readmissionspostAMI.TheWorkGrouprecommendsbalancingregional/multiprovider15andprovider
specificcostdata:
RegionalCosts:Usingregionlevelclaimsdataallowsthepayertotakeintoaccountthecostsofmultiple
providerswithinaregion.Thisemphasizesthefactthatoneproviderscostsmaynotberepresentative
oftheentireregion.Italsoaddressesthevariabilitythatmayexistforaproviderwithalowvolumeof
cases,aslongastheregionislargeenoughtoreflectsufficientvariability.Oneissuewithusingregional
claimsisthatifprovidersinthatregionasawholehavealreadyachievedacertainlevelofefficiency,
theymaybelessabletoachievefurthersavings.Theseregionsortheprovidersinthemcouldargue
thatanefficientregionwillbepunishedforitspreviousworktoachievetheseefficiencies.Onthe
otherhand,iftheregionhasahigherperbundlecostonaveragethanotherregionsorspecific
providerswithintheregion,thepayermayachievefewersavingsthaniftheepisodepricewassetata
nationalorproviderspecificlevel.Whilebasingsomepartofthepriceonregion,itisalsoimportantto
notevariationacrossregionsandtoconsiderwhethervariationacrosstheregionsiswarranted.Itis
importanttolookatthisclosely,andnotjustbakeinregionalvariationifthereisnotanobjective
reasonfordoingso.
ProviderCosts:Providerspecificcostsaretheactualcostsfortheproviderspreviouspatients.For
example,ifthecardiologypracticeistheaccountableentity,thepayerwillconducttheanalysisusing
thecurrentepisodedefinitionandapplyittoitsCADpatientsfromthepasttwoyears.However,this
cancomewithchallengesalthoughthesecostsmaybeaccurateforagivenclinicalpracticewitha
givenpayer,theymaybuildinalreadygainedefficienciesthatmakeitmoredifficulttoachievesavings,
orhavebuiltininefficienciesthatlimitthesavingsforthepayer.
Acombinationofproviderandregionalclaimsexperienceshouldbeusedasdata.Thismixwillensure
boththatthedeterminedepisodepricetakesintoconsiderationtheuniquehistoricalexperienceofthe
specificprovider,andthatgoalsaresetbasedonwhatisfeasibleintheregion.Thisprocesswillalso
requireriskadjustmenttoadjustfortheuniquecharacteristicsofthepopulationtheproviderserves.
Recommendation9,TypeandLevelofRisk,discussesthisfurther.
Establishinganappropriateepisodepriceforaconditionepisodewithanestedprocedureisfarmore
complexthanestablishingapriceforanepisodethatincludesonlyaconditionoraprocedure.For
example,aconditionbundleisintrinsicallycomplexbecauseitisdifficulttoestimatethenumberof
beneficiariesinthebundlewhowillneedprocedures.Moreover,thecostsofanysingleprocedurecan
besignificant.Addingaprocedureintoabundlerequirescreatingabudgetandaccountabilityforthe
procedure,aswellasanoverarchingbudgetforthecondition,includinganestimateofthenumberand
typeofproceduresthatmaybeneeded.Asdifficultasthissounds,thisepisodepricestructurecanset
upmeaningfulincentivesthatpreventtheoveruseofexpensiveprocedures,particularlywhenthereare
moreappropriatealternatives.
InordertodeveloptheCADepisodeprice,theWorkGrouprecommendsthathealthplansdefaulttoan
averagebasepriceforapplyingtheepisodetopatientswhoarenewtotheplanandforwhichno
historicaldataexists.DoingthiswouldlikelyleadtoanupfrontFFSpaymentandretrospective
15
Forpurposesofthispaper,regionisnotdefined.Theregionwillbedefinedasacombinationoftheexperience
ofmultipleproviders.Weusethetermregionaltoreflectthisassumption.
84
reconciliationpaymentflow,sinceaplanmaywanttoconductretrospectiveadjustmentsafteracertain
numberofquartersbasedonpatientresourceuse.TheWorkGroupalsorecommendsthatpayerstrack
thefrequencyofdiagnostictestingoverthefirstquarteroftheepisodeinanewlydiagnosedpatientin
ordertounderstandandassesspricinginsubsequentyears.
Thepricefortheprocedureepisodecanbecalculatedasapercentageallocationcarvedoutfromthe
underlyingconditionepisodeprice.Itisreasonabletoassumethatanaccountableentitywill
automaticallybeoverbudgetinanyonecasewhereapatientrequiresaprocedureorexperiencesa
complication.However,theepisodepricewillaccountforacertainnumberofproceduresthatmay
occuracrossthepopulationasawhole.Onlythoseaccountableproviderswithhigherthanaverage
ratesofprocedures,adjustedforpatientseverity,willhavetotalaverageactualsthatexceedthe
budgets.Recommendation9,TypeandLevelofRisk,describesstrategiessuchasstoploss,whichwill
addresssituationsinwhichaproviderconductsagreaterthanexpectednumberofprocedures.While
thisoveragemaybeduetolackofhistoricaldataintheinitialyearsoftheepisodemodel,itwillbe
importanttoassesswhetheraproviderisconductingproceduresthatmaynotbeappropriateor
necessary.
Theprocedureepisodecouldbepricedwithhistoricaldataappliedtotheepisodedefinitionforthe
procedurethesamebasicfoundationasthecondition.ItwouldbenecessarytocalculatethePCIand
theCABGproceduresseparately.Determiningwhethertodooneortheotherwouldbeinthehandsof
theentityaccountablefortheoverallcondition.
Historicaldata,whereavailable,isessentialtodeterminingtheepisodeprice.Healthplansshould
ideallyuse12to24monthsofpatienthistoricaldata.Thedepthofhistoricaldatawilldifferdepending
onwhetherthemodelisbeingdesignedforMedicare,Medicaid,orforacommercialpayer.One
concernisthatthereisawiderrangeincostandutilizationwithinandacrossmarketsforcardiaccare
thanthereisinacommonprocedureepisode.Oneoptionforstartingtodevelopafullcondition
episodepricewiththenestedproceduresistobeginbypricingtheprocedureepisodes,andbuildingthe
conditionepisodearoundtheprocedure.Thisisparticularlyrelevanthere,sincehistoricaldataon
procedurepricemaybemostfeasibletocollectanduse.Theroleofnegotiatingpowerisalsoanissue.
Priceswillvarybasedonmarketshare.Whilenegotiatingpowerbasedonmarketshareisnothelpful,
CEPcanencouragetransparencyacrossprovidersandexposethesetypesofvariancestodrivemarket
tothosewhoareprovidingahighervalueproduct.
improve.
category.
85
dosowilldependontheavailabilityofdataandanalytictools.Theseinclude:
haveasignificantimpactonapatientshealthstatuspriortothejointreplacementprocedure,accessto
care,andpostprocedurerehabilitationandfollowupcare.Theseincludeincome,literacystatus,living
status(livingalone,livinginacommunitywithoutfamilyorothersupportsnearby),availabilityof
transportation(bothingeneral,andtocaresettings),andothers.Certainsocioeconomicfactorsmay
alignwithaspecificpayercategory,whetheritbeMedicareorcommercialpayers.
publicpayer.Eitherway,thiswillimpactthelevelatwhichtheepisodepriceisset,aswillthemarketin
whichthepayeroperates.Mostprivatesectorpayerswillneedtonegotiatewithprovidersonthe
episodeprice,particularlyifparticipationisvoluntary.Iftheinitiativerequiresparticipation,itmaybe
easiertoestablishanepisodeprice,asisthecasefortheCJR.
fromatrustedsource.Theavailabilityofthesedatatoidentifytheopportunitiesforefficienciesis
criticaltothesuccessoftheseinitiatives.
theirpatients,aswellasbetweenpurchasersandtheiremployees.
Forfurtherdiscussiononthistopic,pleasereadthepaperonFinancialBenchmarking,clickhere.
9. TypeandLevelofRisk
Thegoalshouldbetoutilizebothupsiderewardanddownsiderisk.Transition
periodsandriskmitigationstrategiesshouldbeusedtoencourage
broadproviderparticipationandsupportasbroadapatientpopulationaspossible.
Thegoalshouldbetoincorporatebothupsiderewardanddownsideriskwhensettinganepisodeprice.
Withoutdownsideriskwheretheactualcostsexceedthetargetepisodepricetheaccountableentity
andotherinvolvedprovidershavelessincentivetoredesigncaretocreateefficienciesandimprove
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patientcare.Further,increasesinthecostofcare
deliveryfromyeartoyearoftennegatethebenefitsof
upsidesharingofsavingsduetotherelianceon
historicaldata.Prospectivepaymentincludesbothby
definition.RetrospectivereconciliationwithupfrontFFS
paymentcanbedesignedeithertoonlyshareinsavings
(upsidereward)ortoshareinlosses(downsiderisk).In
somecases,payerswillbeginwithupsiderewardto
allowfortheprovidertoestablishtheinfrastructureand
reengineercarepracticesinordertobecomecapableof
managingdownsideriskinthefuture.
Payerscanutilizestrategiestolimitthatriskorto
transition(phasein)todownsideriskarrangementsover
timeinordertoaddressconcernsrelatedtothelevelof
risk.Thisisparticularlyimportantiftheinitiativeis
voluntaryandparticipationwouldbelimitedwithoutthe
optionforonlyupsidereward.Decisionsabouttype,
level,andtimingofupsideanddownsideriskillustrate
thetensionsbetweenpayersandproviders:more
attractiveriskarrangementsforpayersmaybeless
attractiveforproviders,andviceversa.Consequently,in
theprivatemarket,thesefactorsbecomepartofthe
ongoingnegotiationsamongnetworkparticipantsand
payers.
Aprimarygoalindesigningany
alternativepaymentmodel
arrangementisguardingagainst
unintendedconsequences.Inepisode
paymentforcoronaryarterydisease,
theunintendedconsequencethat
concernsallprovidersbutperhaps
safetynetprovidersmostofallisthe
potentialfordecreasedaccesstocare
forpatientswithpoorhealthstatus,
whichputsthematincreasedriskfor
pooroutcomes.Thismaybecorrelated
withlowersocioeconomicstatusifthe
providerfeelsthatitwillnotbe
possibletoprovidethefullcontinuum
ofcareandachievepositiveoutcomes
withintheepisodeprice.Safetynet
providersinparticularmayneedtime
todevelopadequatereportingand
staffinginfrastructure;andbuild
relationshipsacrosshistoricallysiloed
organizationsinordertofeelprepared
totakeontheriskinanepisode
paymentmodel.
MechanismsforLimitingRisk:Thelevelatwhichthose
risklimitsaresetisacriticaldesignelement.Therearea
numberofquestionstoconsiderincluding:1)willthe
accountableentityberequiredtopaythefulldifferencebetweenthetotaldollarsovertheestablished
episodepriceandtheactualepisodecostsbacktothepayer,orwilllimitsbeestablished?and2)whatis
theoptimalpatientpanelsizeforenablingtheadequatespreadofriskintheeventthatthenumberof
proceduresprovidedoverthecourseoftheepisodeisgreaterthanexpected?Limitsareespecially
importantwhenthefactthatanaccountableentityisaccountableforcareprovidedbyotherproviders
istakenintoaccount.Inthecaseofcardiaccare,whoaccountsforthelargestpercentageofoverall
costs?TheFFSpaymentreceivedbytheaccountableentitythephysicianpracticeislimited
comparedtotheliabilityassociatedwiththeentirecostoftheepisodeovertheestimatesfortheentire
population.
Oneriskmitigationstrategyalreadyaddressedislimitinghighriskcasesthroughexclusions.Following
areadditionalstrategiesusedbyvariousinitiativestolimitriskinanepisodepaymentwhilestill
maintainingasbroadanepisodepopulationasisfeasible.Theseareoften,butnotalways,usedin
tandem.
RiskAdjustment:RiskadjustingtheepisodepricebasedonthepatientseveritywithintheCAD
populationisoneriskmitigationstrategy.Mostinitiativeswillbothincludealistofincludedand
excludedpatientsandhavealistoffactorsthatwouldbeusedtoadjusttheepisodeprice.Therearea
varietyofapproachestocapturingpatientcharacteristics,riskfactors,andotherparametersthat
87
predictCADresourceuseandexpenditures.Forexample,theHealthCareIncentivesImprovement
Institutesevidencebasedcaseratescreateavarietyofpatientspecificepisodesthatrecalibratebased
onvariouspatientspecificseverityfactors(HealthCareIncentivesImprovementInstitute,2016).
AnotherexampleistheSocietyforThoracicSurgeons(STS)NationalDatabase,whichincludesmore
than5.4millionpatientrecords.ThedatabasecontributestotheSTSRiskCalculator,whichallowsusers
tocalculateoutcomessuchasapatientsriskofmortalityandlengthofstay.Whileriskadjustment
methodsarelimitedintheirpredictiveaccuracybasedonclaimsalone,overtime,thesefactorsand
theirweightscanbeupdatedtobecomemoreaccuratebasedonempiricalexperience.However,risk
adjustmentcanpotentiallyleadtogaming.Thiswillneedtobemonitoredtoensurethatcodesarenot
beingoverusedtoobtainhigherpaymentsratherthantoaccuratelyreflecttheconditionorriskofthe
patient.Forfurtherdiscussiononthis topic,please readthepaperonFinancialBenchmarking,click
here.
StopLossCaps,RiskCorridors, and Capital Requirements: Stoplosscapsarealreadydiscussedinthe
contextoftheincludedpopulationasonewayto limittheriskofveryhighcostpatientsatanindividual
patientlevel.Stoplosscapscanalsobeusedonanaggregate levelacrossthe population.Riskcorridors
limittheexposureoftheaccountableentityby establishinganupperlimitoverwhichthe accountable
entitywillnothavetopaybackanyamountofdollarsthat theoverallcostsoftheepisodesmayexceed
theestablishedepisodeprice.Thesecorridorscanalso beplacedontheupsidereward,sothatthe
incentivestolimitcarearelessthantheywouldotherwisebe.Anotherriskmitigationstrategyisto
requiretheaccountableentityto maintainacertainlevelofcapitalinorder tocoverlosses.Whilethese
typesofarrangementsareoftenusedtolimitinsurancerisk, thesameconceptscanalsobeusedinthis
contexttolimitservicerisk.
10. QualityMetrics
Prioritizeuseofmetricsthatcapturethegoalsoftheepisodeatboth
theconditionandtheprocedurelevels.Theseincludeoutcomemetrics,
patientreportedoutcomeandfunctionalstatusmeasures,andsome
processmeasuresrelatedtotheprocedures;usequalityscorecardstotrackperformance
onqualityandinformdecisionsrelatedpayment;and
usequalityinformationandothersupportstocommunicatewith,andengagepatients
andotherstakeholders.
Therearetwotiersofmeasurementnecessaryinthismodelmeasuresthatprovideinformationonthe
qualityofconditionmanagement,andmeasuresthatholdprovidersaccountableforthequalityand
outcomesspecifictoaCADprocedure.BothCMSandcommercialhealthplansuseexistingcardiaccare
measuresofclinicaloutcomesandclinicalprocessesthataddressbothconditionalmanagementcareas
wellasprocedurerelatedcare.Thereshouldbelessfocus,however,onprocessofcaremeasuresand,
instead,agreaterfocusontheuseofepisodelevelmeasuresthatallowforassessmentofpatient
outcomesacrosscaresettingsandproviders.Thatsaid,itismosteffectiveifallstakeholdersinthe
initiative,includingproviders,agreeonthevalueofthemeasures.
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GiventhelackofsystemleveloutcomemeasuresforCADcare,theWorkGrouprecommendsusing
PatientReportedOutcomeMeasures(PROMs)tocollectinformationonpatientsexperienceofcare
fromtheircardiologist/PCP,fromtheirsurgeoninthecaseofprocedures,andfrommeasuresof
functionalstatuspreandpostprocedure,andovertimewithacondition.
Itisimportanttorecognizethepreferenceforalignmentofmeasuresacrossprograms,useofnationally
endorsedmeasures,andalimited,tightsetofmeasureswithalowburdenofcollectionwhenselecting
themetricsforanepisodepaymentmodel.TheWorkGroupsupportstheseprincipleswheneverthey
canbemetwithmeasuresthatincentpriorityopportunitiesforimprovingCADcare.Ameasurethat
meetsthesecriteriawithoutthepotentialforclearbenefitsamongCADpatientsisnotrecommended
becauseitwouldnotbefitforthispurpose.TheWorkGroupisnotincludingrecommendationsfor
specificmetricsatthistime.
PotentialMeasures:Table10describesexamplesofpotentialmeasures,mostofwhichareincludedin
theCoreQualityMeasuresCollaborative(CQMC)ConsensusCoreSetofCardiovascularMeasures
Version1.0(CentersforMedicare&MedicaidServices,2016b).TheCQMCdividesthesetintochronic
careandacutecareaccountabilityandspecifieswhetherthemeasuresthemselvesareatthehospitalor
thephysicianlevel.TheWorkGrouprecommendsconsideringthemeasuresinTable10asamenuof
potentialoptionsfordevelopingacoremeasuresetforCADepisodepayment.
Table10:PotentialCADRelatedQualityMeasuresforUseforAccountabilityand/orPayment
Measure
Examples
Clinical
Outcomes
Hospital30dayriskstandardizedreadmissionratefollowingCABG(NQF#
2558)
Hospital30dayunplannedriskstandardizedreadmissionratefollowingCABG
(NQF#2515)
Hospital30dayriskstandardizedreadmissionratefollowingAMI(NQF#0505)
Hospital30dayriskstandardizedreadmissionratefollowingPCI(NQF#X)
30dayriskstandardizedmortalityratefollowingPCIforpatientswithSTEMI
(NAF#0536)orwithoutSTEMI(NQF#0535)
RiskadjustedoperativemortalityforCABG(NQF#0119)
PrimaryPCIreceivedwithin90ofhospitalarrival(NQF#0163)
InhospitalRiskAdjustedRateofBleedingEventsforPatientsUndergoingPCI
(NQF#2459)
PotentiallyAvoidableComplicationsMeasures
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Measure
Examples
Clinical
Processes
ChronicStableCAD:ACEinhibitororARBtherapy(NQF#0066)
ChronicStableCAD:Antiplatelettherapy(NQF#0067)orbetablockertherapy
(NQF#0070)
TobaccoUse:ScreeningandCessationIntervention(NQF#0028)
Therapywithaspirin,P2Y12inhibitorandstatinatdischargefollowingPCI
(NQF#0964)
Postdischargeappointmentforheartfailurepatients(NQF#2439)
CAHPSClinicianandGroupSurvey
CAHPSSurgicalCareSurvey
Gainsinpatientactivationscoresfrom612months(PatientActivation
Measure)(NQF#2483)
Appropriate
Use
CardiacStressImagingNotMeetingAppropriateUseCriteria:Routinetesting
afterPCI(NQF#0671)
Functional
Status
SeattleAnginaQuestionnaire
TheContinuityAssessmentRecordandEvaluation(CARE)tool(measures
healthandfunctionalstatusuponhospitaldischarge,changesinseverity,and
otheroutcomes)
Mentalhealthstatusfollowingcardiovascularevents
Symptommanagementmeasures
Measuresofuseofcardiacrehabilitation
FollowupvisitafterhospitalizationbyPCP
CareTransition
Coordination
Patient
Reported
Outcomes
Measure
Conceptsfor
Development
Thegoalofepisodepaymentistoachieveimprovedoutcomesforpatient.Asaresult,itisimperative
fortheCADepisodemodeltoincludeclinicaloutcomemeasuresforthepurposeofaccountabilityandin
ordertotrackwhetherthecaredeliveredisorisnotachievingthegoal.However,unliketheLAN
recommendationsonepisodepaymentformaternitycareandelectivejointreplacement,theWork
GroupdoesrecommendtheinclusionofsomeclinicalprocessmeasuresforCAD,duetothelinkthat
certainprocessmeasureshavetopatientoutcomes,and/ortheircorrelationtomeaningfulcare
transitionefforts.
QualityScorecard:Incorporatingperformanceonmetricsintoscorecardsforensuringhighqualitycare
delivery,informingthedecisionsofthepatient,familycaregivers,andproviders,andusingthe
scorecardtodeterminepaymentlevelsarecorefeaturesofanyepisodepaymentinitiative.This
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informationwillbecriticalforengagingpatientsindecisionsrelatedtochoiceofproviderandsetting
andtypesofcaredelivery.Below,wedescribeinmoredetailthepotentialmeasuresthatcouldbeused
andthemannertheywouldbeused,bothinascorecardandforinformationpurposesforpatientsand
otherstakeholders.
meetorexceedinordertoreceiveeitherthefullreimbursementforanepisodeorthefullshared
savings.However,thedecisiononwherethosethresholdsaresetorhowtheyareusedshouldbeleftto
thepayerandprovidertonegotiate.Someinitiativesvarythelevelofsharedsavingsbasedon
performancemetrics,whileothersalsouseminimumperformancelevelsasathresholdforreceiving
anyportionofthesavings.Inaprospectivelypaidinitiative,itmaybeusefultowithholdsomeportionof
theprospectivepaymentandbaseitspaymentorlevelofpaymentonthereportingofandperformance
onthequalityscorecard.
Arichsourceofmeasuredatafordevelopingaqualityscorecardexistswithincardiaccarerelated
registries,suchastheSocietyofThoracicSurgeons(STS)NationalDatabase.TheSTSregistrywas
establishedin1989asaninitiativeofcardiothoracicsurgeonsseekingtoimprovethesafetyand
outcomesofcare.Theregistryaffordscardiothoracicsurgeonsacrossthenationastandardizedformat
forcollectingasetofdataelementsrequiredtosystematicallymeasureandcomparesurgicaloutcomes.
Thesystememploysrobustriskadjustmentandbenchmarksthatbothenablecomparisonacross
providersandovertime,andthatformthebasisforsharingbestpracticesandmotivatingcontinuous
qualityimprovement.Moreover,since2010,theSTShasfacilitatedthepublicreportingofresultsof
surgicalqualityandoutcomesforproceduressuchasCABGandaorticvalvereplacement(AVR),among
others.TheworkoftheSTSandotherswithintheNationalQualityRegistryNetwork(NQRN)couldbea
majorcontributiontothepotentialforincorporatingclinicallyrichoutcomemeasuresforpriority
conditionsandproceduresintoCEPmodels.
QualityInformationtoCommunicateandEngagewithPatients:Inadditiontousinginformationon
qualitytodeterminepayment,itisimportanttomanystakeholderstohaveaccesstodataonquality.As
discussedunderRecommendation5,PatientEngagement,patientsneedqualitydataonthe
performanceofdifferentprovidersprimarycare,cardiology,surgeons,andintensiviststoinform
theirchoices.Patientsalsoneedinformationaboutthedifferentfacilitiesinwhichtheirproceduresmay
takeplace.
Oneexampleofpublicreportingofcardiacsurgeryperformanceatboththehospitalandthesurgeon
levelistheSTSPublicReportingInitiative.ThoughtheSTSinitialeffortsfocusedonCABGperformance,
ithasalsoaddedqualitydataonAorticValveReplacement(AVR)surgery.TheSTSusesacomposite
CABGscorethatincludes11differentcomponentsofclinicalcare,whichincludebothmortalityand
morbidityratesandadherencetoNQFendorsedqualitymeasures.Itsstarratingsystemisdesignedto
allowpatientstoviewaprovidersperformanceagainsttheaverageperformanceofallSTSdatabase
participants.
Employers,purchasers,andpayersalsoneedthesedatabothtodevelopprovidernetworksandtohelp
employeesmakethesechoices.Employeesneedtounderstandthebundleandwhattheirroleisin
providinghighqualitycare.
Finally,episodepaymentdesignmustbuildinthecapacitytocollect,analyze,andprovidedata;andto
supportCADpatientsandconsumersinidentifyingandinterpretingthisinformation.Theuseofpatient
navigatorsforwhomsomeexistinginitiativeshavesubstitutedcommunityhealthworkerscanbe
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helpfulinprovidingthissupport.First,however,theinformationitselfmustbeavailable.Itisimportant,
therefore,toestablishcrosscuttingeffortstodefinemetricsandsystemsfordatacollectionand
analysis.Itisasignificantburden,however,foreachinitiativetodefineitsownmetrics,collection
system,andscorecard.Broadereffortsareneededtobuildthenecessaryinfrastructureformeaningful
developmentanduseofqualityperformanceinformation,andbuildingthesesystemsisoneofthekey
challengesdiscussedinChapter6,OperationalConsiderations.ToreadtheLANWhite Paperon
PerformanceMeasurement,clickhere.
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Insertcoverpage
93
Chapter6:OperationalConsiderations
Inthissection,theCEPWorkGroupdoesnotofferspecificrecommendations.Instead,theWorkGroup
hasdevelopedasetofquestionsthatalladoptersofclinicalepisodepaymentshouldconsiderand
discusswhentheybeginplanninganddesigningepisodepaymentmodels.
Whilethedesignofanepisodeofcareiscriticaltoitssuccess,someaspectsofthewayepisode
paymentsareconductedaffectthelikelihoodthatpayersandproviderswillbeabletoadoptagiven
model.Theseoperationalconsiderationsinclude:remainingmindfuloftheperspectivesofstakeholders;
buildingandmaintaininganappropriateinfrastructurefordatacollection,analysis,andpayment;
stayingabreastofregulatorystatutesandregulationsthatcouldaffectthedesignandoperationof
episodepayments;and,finally,consideringhowepisodepaymentsinteractwithpopulationbased
payments(Figure12).
Figure12:OperationalConsiderations
1. RoleandPerspectivesofStakeholders
Howdotheperspectivesofstakeholdersimpact
thedesignandoperationofclinicalepisodepayment?
Itisimportanttounderstandthevariedperspectivesofthosewhowillbeimpactedbytheclinical
episodepayment.Eachstakeholder,whetherpayer,provider,consumer,orpurchaser,hasunique
expectations,goals,andlimitationsduringthedesignofanepisodepayment.Becauseofthemultiplicity
ofthesediverseperspectives,itisimportanttoconsiderallstakeholdervoicesinthedesignand
operationofepisodepayments.
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Manystakeholdershavemultipleand
sometimesconflictingviewpoints.For
example,commercialhealthplansandlarge
payers(includingstatesandthefederal
government),maybeinterestedincreating
incentivesforproviderstodevelopthe
capacitytoinvestindatainfrastructureto
supportthatgoal.Meanwhile,providers
maybeequallyinterestedinthepotentialof
episodepaymentsandcanbevaluable
innovators.Buttheymayhavereservations
aboutleadershipandaccountabilitywhenit
comestocarecoordinationacrossmultiple
medicalsettings.Involvingpatientsand
familiesinmyriadwaysthroughoutthe
episodeaspartnersintheirowncareandin
thedesign,implementationandevaluation
ofepisodepaymentmodelsisanessential
strategyforadvancingvaluebasedcareand
improvingoutcomes.Theycanalsoprovide
valuablefeedbackonhowthemethodology
impactsthepatient.
Finally,becauseoftheirpurchasingpower,
employersandotherentitiesthatpurchase
healthcarecanalignincentivesbetween
themselvesandprovidersthroughepisode
payment.Purchasersinterestscoincide
withthoseofconsumersandpatients,
becausebothgroupsshareavestedinterest
inensuringthatepisodepaymentmodelstie
reimbursementtoperformance.
StakeholderPerspectives
PatientsandConsumers:Patientsandtheirfamilies,caregivers,
andconsumerscontributeto,andbenefitfrom,episode
paymentmodels,includingbyparticipatingindesign,
governance,evaluation,andimprovementofepisodepayment
models.Theycanusehighqualitydecisiontoolstodecideabout
appropriatecare.Whenpatientsandcaregivershaveaccessto
meaningfulqualityandcostinformation,theyareabletomake
thoughtfulcarearrangementsthatfavorthehighestvaluecare
andproviders.Patientsandfamiliescanparticipateinshared
careplanningandbenefitfromcarecoordinationtoimplement
careplansandmonitorquality.Finally,consumersandpatients
canprovideimportantfeedbackoncareexperiencesand
outcomes,whichhelpsmeasuresuccessanddriveimprovement.
Healthinformationtechnologyfacilitatestheirinvolvement
throughouttheepisode.
Payers:Payers(commercialhealthplans,Medicare,and
Medicaid)seektocreateincentivesforproviderstocoordinate
careacrossprovidertypesandthus,createefficienciesthat
decreasecostsforabundleofservices.Theyareoftenwillingto
investinstrongdatainfrastructureforepisodepayment
implementation,aswellasdevelopnewcontractingprocedures
withparticipatingproviders.
Providers:Providers(cliniciansandfacilities)lookforindicators
ofsufficientleadershipandaccountabilityforepisodepayment
tobeestablishedtoensurethatthegoalsofcareredesignand
carecoordinationacrosssettingsandprovidersareprioritized
overcostsavings.Theyareinterestedinaligningfinancial
incentives,datarequirements,andqualitymeasurement
requirementsacrossallpayerswithwhichtheycontract.
EmployersandPurchasers:Purchaserscanadvancethegoalof
aligningincentivesbetweenthemselvesandprovidersthrough
episodepayment.Purchasersmayalsobeinterestedin
integratingtierednetworkswithinabundledpaymentmodelto
provideincentivestoemployeestoseekcarefromhigh
performingprovidersandinimprovingvaluethroughenhanced
benefits.Largepurchasersholdsignificantleveragewithpayers
andprovidersandcanpushforepisodepaymentwithintheir
contractingnegotiations.Inthecaseofmaternitycare,this
leverageisheldbyemployersandstateMedicaidagenciesthat
canencouragetheirmanagedcareorganizations(MCOs)touse
bundledpaymentformaternitycare.IntheCADepisodemodel,
purchasersmayneedtodevelopdifferenttoolsfornegotiating
multiyearcontractswithpayers,giventhefluctuationincare
needsforpatientswithCADfromthepointofdiagnosistoactive
managementandbeyond.
Welldesignedpaymentmodelsconsiderall
oftheperspectivesabove,aswellas
supportreliabledeliveryofcarethatis
providedattherighttimeintheright
setting.Anotherconsiderationthatimpacts
therolesandrelationshipsamongthe
variousstakeholdersiswhetherthe
initiativeisvoluntaryormandatory.For
example,ifagivenmarketischaracterized
byhavingsignificantalignmentofmultiple
payersorhasonedominantpayer,thereis
greateropportunityforapayertomake
participationmandatory.Whetheritisvoluntaryormandatory,thenegotiationsamongproviders,
purchasers,andpayerswillneedtoensurethatparticipationisfeasibleforthosetowhomitapplies.
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2. DataInfrastructureIssues
Whatdatasystemsdopayers,providers,andconsumersneedto
successfullyoperationalizeepisodepayment?
Oneofthebiggestchallengestoimplementingaclinicalepisodepaymentmodelistheprocessof
managingandsharingthevastamountsofdatanecessarytoassess,manage,andmitigateriskandto
useittoimprovequalityandoutcomesforpatients.Effectivedatainfrastructuresystemsmustbeable
toachievetwothings:
Groupclaimsintoepisodesforanalysisandpayment;and
Meetprovidersneedforcriticalpatientinformationtobeaccessibleacrossprovidersandto
patientstocoordinatecareandengagepatientsintheircare.
Atpresent,thefieldlacksscalableinfrastructureforwidespread,effective,efficientadoptionofepisode
basedpayment.PayersystemsaresetupforFFSpayment,or,insomecases,fullcapitation.The
intermediatestepsofbundledpaymentrequirepullingclaimsfrommultipledatafiles,applying
exclusionaryrules,calculatingandupdatingbenchmarksandtargetepisodeprices,anddoingsowithin
thecontextofmultipleprovidercontractsandenrolleebenefitdesigns.Simplyput,somepayersare
strugglingtodevelopthebusinesscaseandjustifythereturnoninvestmentforbuildingthesesystems.
Forepisodepaymenttoachieveitspotentialrequiresadatainfrastructurethatsupportsandfacilitates
analysisforthefollowingpurposes:
Determiningwhichclinicalepisodes/conditionstotargetandwhatservicesandcostsareconsidered
partoftheepisode;
Establishingtheepisodeprice;
Bundlingclaimstodeterminehistorical/actualexpenditures;and
Communicatingclinical,patientgenerated,andcarecoordinationdataacrossproviders,including
primaryandspecialtyphysicians,hospitals,postacutecaresettings,andotherswhoarepartofthe
patientscareteams.
Thisdatainfrastructuremustalsosupporttheabilityofclinicianstounderstandpatientpreferencesand
expectations,andforpatientsandfamilycaregiverstocommunicatepreferencesandgoals.Forthese
purposes,anepisodepaymentdatasystembyitselfmaynotbesufficient.Otherclinicaldataand
patientdecisionaidinformationwillalsobeimportant.However,thepaymentsystemsthatanalyzeFFS
claimsdatacanalsoprovideimportantinformationonthetypesofclinicaldecisionsandtheimpactof
thosedecisionsonpatientsexperiencingsimilarconditions.
Inaddition,whetherclinicalepisodepaymentisprospectiveorutilizesretrospectivereconciliationwith
upfrontFFSpayment,itiscriticaltobuildandimplementsoftwareandsystemstogrouptheseclaimsto
estimateandestablishtheepisodeprice,tocalculateactualcosts,andtomakethecorrectpayment
adjustments.Currently,thedataanalysisandsystemsbeingusedaretoomanual,andtheexpenseof
eitherreplacingorbuildingthistypeofprocessontopoflegacysystemswilllimitbroader
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implementationofepisodepayment.Dependingonthevolumeofpaymentthatisdoneinthismanner
andthemonetaryimpact,revisinglegacysystemstobeabletohandlethislevelofcomplexitymaynot
beahighpriorityforapayer.Payersarefacedwithabuyorbuildscenariowherebytheycaneither
buythecomplexinfrastructure,albeitwithlittleknowledgeaboutthequalityoftheproduct,ortryto
builditthemselves,withtheunderstandingthatitwillbealongterminvestmentinthistypeof
paymentreform.Althoughtheneedsarecomplex,somecompanieshavedevelopedthecapacityto
assistpayersandprovidersinthesefunctions.Furthermovementtowardtheuseofclinicalepisode
paymentswillcreateanevengreatermarketforsuchserviceswhethertheyaredevelopedbyathird
partyorwhetherthepayercreatestheirownsolution.
Moreover,thesesystemsmustbeabletosupportdatasharingwithprovidersandpayersina
transparentmannertoensurethatallinvolvedunderstandwheretheopportunitiesforefficienciesand
improvementsincareoccuracrosstheepisode,includingpotentiallyindividualpatientmanagement.
However,itisoftenverydifficulttoobtainusefuldatainasufficientlytimelymannertoallowforthe
mosteffectivecaremanagementofthepatient.Anotherissueisthecapacityforproviderentities,and
insomecases,payers,toanalyzethedata.Eveniftheunderlyingclaimsareavailableandthelogicfor
runningthedatawasshared,providerentitiesoftenfinditchallengingtorunthenecessaryreports.
Finally,forthecaretobeaseffectiveaspossible,digitalsystemsthatprovideinformationtopatients
andenablethemtocommunicatewiththeirprovidersandtakeanactiveroleintheircarearealsokey
andmustbetiedtotheproviderdataanalytics.Thegroupingofclaimsisprimarilyapayerfunction;
however,theclinicalinfrastructureissomethingthataprovidermaywant/needtodeveloponitsown,
oritispossiblethatapayercanassist.ThisisacriticaldecisionpointwhenimplementingCEP.
TheWorkGrouprecommendsthefollowingtwoconceptsforoperationalizingthedatainfrastructure
neededtoimplementepisodepayment.
AServiceorUtilityModel:Inthismodel,agroupofpayerspayathirdpartytodevelopacoresetof
logicthatcouldbeusedtogroupclaims;providefeedbackandbenchmarkingtoproviders;andsupport
datasharingforpatientmanagement,insteadofeachpayerhavingtodevelopthecapacityindividually.
SeveralexampleswereprovidedbyWorkGroupmembersincludingvendorsthatareperformingthis
capacity;largepayers,suchasMedicaidinonestate;andregionalinitiativeswherebypurchasersor
payerssupportathirdpartytoperformthesetasksinauniformmanner.StatesponsoredAllPayer
ClaimsDatabases(APCDs)areanexampleofadatawarehousethatcouldpulltogetherdataacross
payersforthesepurposes.Inanyimplementationscenario,neutralsourcesofsuchdataandanalysis
willhelptofacilitatemultipayeranalysis.Thisensuresthatprovidersinvolvedinthisformofpayment
arenotsubjecttomultipledefinitionsofepisodesandbenchmarkingformulas.Anotherconceptthat
wasimportanttotheWorkGrouptoensurehighqualityproductswastopotentiallycreatea
certificationprocessforthistypeoffunction.
ACoreSetofLogic:Acoresetoflogicwillassistthehealthcareindustryindevelopingthecapacityfor
groupingclaimsintobundlesbystandardizingthecorelogic,butallowingeachpayertocustomizea
portionofthemoregranularrules.Thiscouldbeappliedindividuallybypayersorwithinthecontextofa
thirdpartydescribedabove.
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3. RegulatoryEnvironment
Howcanthecurrentandevolvingfederalandstatelegallandscape
inthehealthcareindustryaffectepisodepaymentimplementation?
Anyorganizationpursuinganepisodepaymentinitiativeneedstoremaincognizantofthestatutoryand
regulatoryframeworkthatmayimpactthemannerinwhichitcreatesrelationshipswithprovidersand
thewayincentiveandriskstructuresareestablished.
Themannerinwhichclinicalepisodepaymentisdesignedandimplementedwillbeaffectedbyexisting
andemerginglawsandregulationsatboththefederalandstatelevels.Certainarrangementsand
relationshipsbetweenprovidersandsuppliers,aswellasbetweenpatientsandprovidersandsuppliers,
mayimplicatefederallawsandregulationsdesignedtopreventinappropriateincentivesandtoprotect
beneficiaries.Further,manystateshavecreated,orareconsideringcreating,regulationsdesignedto
ensurethatprovidersdonottakeonalevelofriskthattheymightnotbeabletosupportwithout
harmingthepatientorotherconsumers(regardlessofwhetheritischaracterizedasinsuranceor
servicerisk).
Threefederallawsofsignificantimportancetohealthcaresystemsarethephysicianselfreferrallaw,
theantikickbackstatute,andthecivilmonetarypenalty(CMP)laws.Itwillbeimportantforprovider
organizationstodiscusswithlegalcounselthepotentialimplicationsoftheseandotherlawson
proposedarrangementsforclinicalepisodepayment.HHSissuedlimitedwaiversoftheselawsfor
specifictypesofmodels,includingtheBundledPaymentforCare Improvement(BPCI)initiativeandthe
CJR.MorediscussioncanbefoundontheCMS Fraud andAbuseWaiverswebpage(Centersfor
Medicare&MedicaidServices,2016c).
Severalotherlegalissuesalsoimpacttheimplementationofclinicalepisodepayment.Forexample,
EMTALAisanimportantconsiderationwhenpricingthethreeepisodesofcarediscussedinthispaper.
Patientsbeingseenforthefirsttimeintheemergencyroomwillbegivenwhatevercarethehospital
andclinicianoncalldeterminefeasiblewithoutregardorawarenessoftheclinicalepisodepayment
context.Thismaybeparticularlyimportantformaternityepisodesifthebundledpaymentisdeveloped
usingthecostofabirthcenterbirth.
Regardingmedicalliability,itmaybethecasethatcliniciansandfacilitiesneedtoconsiderconcerns
relatedtoliabilitywiththeirpreferredtreatment.Theremayalsobeconcernswithliabilitywhen
multipleprovidersaresharingaccountabilityinateambasedapproach.Payersneedtobeawareofand
acknowledgetheseconcerns.Withmaternitycare,liabilitylawsfortheclinicians(includingOB/GYN,
midwives,andbirthcenters)varyacrossstatesregardingbirth;thoseestablishingamaternitycare
initiativeshouldhaveanunderstandingoftheirstatelaws.
Manystateshavecreated,orareconsideringcreating,regulationsdesignedtoensurethatprovidersdo
nottakeonalevelofriskthattheymightnotbeabletosupportwithoutharmingthepatientorother
consumers(regardlessofwhetheritischaracterizedasinsuranceorservicerisk).
Inaddition,wenotethat,givenlimitsonreassignmentofclaims,ifastatepaysFFSforEJR,Maternityor
CardiaccareunderMedicaiditmaynotbefeasibletoprospectivelypayforaclinicalepisodeofcareto
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oneaccountableentitythatwouldthenremunerateotherproviders.16Wehighlightthisissuefor
maternitybecauseoftheimportanceofMedicaidasapayer,butitisrelevanttotheepisodetypesas
well.
Inthematernitycontext,wefoundevidencethatitmaybehelpfulforthevariousparticipantstoknow
thataseriesofevaluationsofrigorousqualityimprovementprogramshasdocumentedrapidly
plummetingliabilityclaims,payments,andpremiums(Sakala,Yang,&Corry,2013).Itwillbeimportant
toincludethesedimensionsofcareinevaluationsofepisodepaymentmodelsbecauseofthis
relationship.
RegulatoryAreasThatMayAdditionallyImpactMaternityPaymentStrategy
Statesdefinethetypesofproviders,includingpractitioners,andsettingsofcarethatsupportbirth.They
definelicensureandcertificationofprovidersandthescopeofpracticeunderwhichtheproviders
operate.Ataminimum,theseregulationswillimpactdecisionsrelatedtoparticipatingproviders,services
covered,andepisodepricedetermination.Forexample,lawsthatrequirewrittenagreementsfortransfers
betweenbirthcentersandhospitalsorthatrequireOB/GYNsupervisionofbirthsinabirthcentercanlimit
theavailabilityofthatbirthingoptionifnohospitalorOB/GYNiswillingtoengageinsuchanagreement.
Otherstatelawscreateadifferentminimumlengthofstayforabirththanthefederalminimumandmay
alsoneedtobeconsidered.
TheMedicaidcontextisimportanttoconsider,givenalargenumberofbirthsarepaidforbyMedicaid.A
highpercentageofthosebirthsarepaidthroughMCOs;therefore,itwillbeimportanttoconsiderthe
mannerinwhichastatecontractswithMCOs.Thesecontractsmustdeterminewhetherstatescould
encouragesuchpaymentarrangementsorwhethertheMedicaidMCOsmaybeinterestedinpayingfor
maternitycareinthatmannerwithoutstateencouragement.Thereareexampleswherebyastate
encouragesthesetypesofpaymentarrangementsthroughtheircontractedMCOs;whereas,otherstates
haveMCOsbuildbundledpaymentsformaternitycareintotheircontractswithproviderswithoutstate
encouragement.Wenotethat,givenlimitsonreassignmentofclaims,ifastatepaysFFSforbirthsunder
Medicaiditmaynotbefeasibletoprospectivelypayforaclinicalepisodeofcaretooneaccountableentity
thatwouldthenremunerateotherproviders.
Manystateshavecreated,orareconsideringcreating,regulationsdesignedtoensurethatprovidersdo
nottakeonalevelofriskthattheymightnotbeabletosupportwithoutharmingthepatientorother
consumers(regardlessofwhetheritischaracterizedasinsuranceorservicerisk).
SeeSection1903(a)(32)oftheSocialSecurityActandtheregulationsat42CFR447.10.)
16
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4. InteractionbetweenCEPandPopulationBasedPayment
Howdoclinicalepisodepaymentandpopulationbasedpaymentinteracttomove
paymentreformforward?
AstheLANdevelopsrecommendationsspecifictoimplementingeitherclinicalepisodepaymentor
populationbasedpayment,questionsarisefromthoseinthefieldwhoseeopportunities,oratsome
pointinthefuture,mandates,relatedtoimplementingbothofthesealternativepaymentmodelswithin
oneorganization.Therearemanyquestionsthatpayers,purchasers,andproviderswillneedtothink
aboutandaddresswhendeterminingwhetherandhowtoimplementmultiplepaymentmodels.The
discussionherecentersonintegratingbothCEPandPBP,butmayapplytootherAPMsaswell.
Itiscriticalthatthedecisiontoimplementbothofthesepaymentreforms(eitherseparateortogether)
willbetakenwithinthecontextofabroaderstrategicgoal.AsthehealthsystemmovestowardAPMsof
alltypes,aclearvisionisneededtoavoidconfusionandunnecessarycomplexity.Insomeinstances,it
maybethecasethatusingCEPwillincentivizethenecessarydeliverysystemchangestoensureperson
centeredcare.Inotherinitiatives,payersmayimplementPBPandfindthatclinicalepisodeswithinthe
continuumofcarebecomepersoncenteredwithoutCEP.Establishingagoalforadoptingoneor
multipleAPMsandmeasuringmovementtowarditiscritical.
ImplementingoneAPM,eitherCEPorPBP,hasitsownchallenges;thesechallengesarecompounded
whenanorganizationconsidersimplementingbothtypesofAPMs.Questionsthatarisewhen
implementingbothCEPandPBPmayinclude:
Caninitiallyimplementingthemodelthatfocusesontherisklimitedtoanepisodeofcare(clinical
episodepayment)serveasatransitiontoimplementingthebroadermodelofpopulationbased
payment?Ifso,how?
WhataresomepotentialoperationalpracticesforimplementingCEPandPBPinanintegratedway?
CanClinicalEpisodePaymentServeasaTransitiontoImplementingPopulationBasedPayment?
AspolicymakersandpayersconsidervariousAPMs,themovementtowardPBPisoftendescribedasa
progressionfromlessdisruptiveformsofAPMstomoredisruptiveforms.Forexample,
accountabilityforvalueintheHCPLANFrameworkCategory2(FFSlinktopayment/quality)isonly
relatedtotheservicesprovidedbyindividualproviders.InCategory3,accountabilityforvalueisacross
severalsettingsandproviders,butnotall.Category4holdsoneentityaccountableacrossallcareforthe
enrollee.ThusonequestioniswhetherCEPcan(orshould)serveasanappropriatesteppingstone
towardapotentialgoalofbroadpopulationbasedpayment.
Whileitmaybethecase,asnotedbelow,thatimplementingCEPbeforeaPBPreformmayhelpbuilda
foundationforPBP,itisalsothecasethatCEPisagoalonitsown.CEPcanbequitecomplexto
implementasitrequiresdefininghardtodefinebeginningsandendingsofepisodeswithinthe
continuumofpatientcareandalsoseparatingoutthecostsoftheepisodefromothercostsofcare.
Thesedistinctionsarenotalwaysclear.Thus,implementationofCEPshouldnotbeconsideredonlyasa
steppingstonetoPBP.ItmayalsobethecasethatapayerorproviderfindsCEPonitsowntobe
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effectiveatfocusingonthetypesofcareofmostinteresttoitspopulationandthus,seenoneedto
implementPBP.
WhileCEPcanbeimplementedonitsown,belowaresomewaysinwhichCEPcouldencouragethe
developmentofinfrastructureandrelationshipsamongprovidersthatwouldbeusefulformoving
towardPBP:
Encouragingproviderstocreatemechanismsforcoordinatingacrosssettingswithinaclinical
episodeand,potentially,withprimarycarebeforeandaftertheepisode.Themechanismsand
infrastructureneededtofacilitatethiskindofcoordinationwouldcreateafoundationfor
coordinatingcareinaPBPenvironment.
Creatingexpectationsforaccountabilitybeyondaprovidersownsettingandforthepatientover
time.Accountabilityacrosssettings,clinicians,andphasesofthecarecontinuumiscriticalforPBP
andCEP.Acultureofsharedaccountabilityandteambasedcareisparticularlyimportantgiventhe
needtomeasurepatientreportedoutcomesandkeyqualitymetricsacrosssettingsinbothmodels.
Incentivizingnewstructures,includingcaremanagementprotocols,informationsharingsystems,
andongoingqualityimprovementprogramsthatmakeitmorefeasibletotakeonadditionalrisk.
Providingexperienceforproviderstolearnhowtotakeonfinancialriskanddistributepayment
acrossproviders.
CliniciansparticipatinginaCEPmodelwilllikelyneedtoshareaccountabilityacrossmembersofa
patientscareteam,andwillrequiretheinfrastructuretosupportthat.Buildingthisinfrastructurefor
CEPmaymakeiteasierforthemtobecomeanentitycapableoftheriskinvolvedinaPBParrangement.
Fromthepayerorpurchaserperspective,itmaybeeasiertobeginwithCEP,asitrequireslesschangein
organizationbillingsystemsandwillbeappliedtoasmallersubsetofclaims.Asbillingsystemsbecome
morefacileatgroupingclaimstodefinetheepisodes,thatcapacitycouldbeusedtoassisttheprovider
organizationintargetingtheirinterventionsonepisodesandconditionswiththegreatestopportunity
forimprovementandcostsavingsunderaPBPmodel.
OperationalizingIntegratedCEPandPBPModels
Inanintegratedmodel,itispossiblethattheclinicalepisodepaymentwillnestwithinthepopulation
basedpayment.ThisisbecauseaPBPmodelholdstheaccountableentityresponsibleforthecostsand
qualityofcareforallservicesanalignedenrolleeusesacrossacontinuumofcare,whiletheCEPmodel
willfocusontheepisodicportionofthatcare.Fromaclinicalperspective,havinganaccountableentity
underaCEPprogramwithinaPBPmodelcouldcomplementtheprimarycarefocusofthePBPmodel.
ThePBPaccountableentitywillhaveaneedtopreventsomehighcostepisodes,butalsotoeffectively
managethosethatdooccur.Inthisway,CEPcouldassistthePBPaccountableentityreachitsfinancial
andqualitybenchmarkgoalsbymanagingspecifichighcost,highvolumeepisodeswithinthe
continuumofcare.However,thiscomplementaryrelationshipisonlyfeasibleiftheproviders
themselvescoordinatetheprimary,specialty,andpostacutecareforthepatientbothbeforeandafter
theepisode.
Beforetacklingtheseclinicalquestions,however,thereareanumberofoperationalissuesthatmustbe
addressedwhentwoentitieshaveresponsibilityforcoststhatmayariseforonepatient,butcouldbe
attributedtobothaclinicalepisodeandapopulationbasedcareservice.Theprimaryissuewhen
integratingCEPandPBPisthatapatientmaybeattributedtotwoentitiesatthesametime:thePBP
entityfortotalcostofcare,andtheCEPentityifthepatientneedscarethatalignswithaclinical
101
episode.Usingacarveoutmechanismorsomevarietyofcarveoutcanaddressthissituation.Inthe
threecarveoutexamplesprovidedbelow,weassumethateachsituationinvolvesasinglepayer
(Medicare,stateMedicaidagencyorMedicaidorMedicareMCO,oracommercialpayer)implementing
bothCEPandPBPinthesameregion:
1. BasicCarveOut:Themoststraightforwardwaytoaddressthisistocarveoutthedollars
representedbythoseepisodesfromthetotalcostofcarebaselinecalculationforwhichthePBP
entityisaccountable.Thepayerwouldkeeptrackofthemembersandtheircostsassignedto
theseepisodes,andsubtractthemoutwhenpaymentisreconciled.Thebenchmarkswouldbe
basedontheseamounts.
2. CarveOutwithMetricBasedProviderAccountability:Acriticismofthebasiccarveoutisthatit
providesnoincentiveforthePBPentitytocoordinatewiththeCEPentityforthingssuchas
upfrontshareddecisionmaking,orhighquality,coordinated,followupcareforthepatientpost
discharge.Onewaytoaddressthismightbe(whenusingthebasiccarveoutmethodology)to
usequalitymetricstoholdprovidersaccountable,andencouragePBPentityproviderstowork
withtheCEPentitytomakesurethememberorpatientreceivedseamlesscarearoundthe
episode.
3. CarveOutwithSavingsAssignedtothePBPEntity:Anothercriticismofapurecarveoutisthat
carvingoutthecostsofanepisoderemovespartoftheincentiveforentitiestoenterintoPBP
arrangementsastheyarenotabletoobtainallofthesavingsfromtheirefforts.Onewayto
addressthisistoeitherestablishthepricelessthanthehistoricaverageepisodeprice
(essentiallybuildinginaguaranteeddiscountlevel).ThePBPcouldabsorbtheseupfrontsavings
whiletheCEPentitywouldaccepttheriskbeyondthatamount.
Forsomeproviders,thisdiscussionmaystillbeintherealmofthetheoretical.Forproviders
participatinginvariousACOmodelsandwishingtoparticipateinanewepisodebaseddemonstration
initiative,thesequestionsandchallengesareimportant.AsAPMimplementationevolves,thehopeis
thatpromisingpracticeswillemergetosupportprovidersandpayersinsuccessfuldesign,
implementation,andsustainabilityofsuchintegratedmodels.
102
Chapter7:Conclusion
Overall,therecommendationsdevelopedbytheCEPWorkGroupincludedesignelementsand
operationalconsiderationsthattogetheraredesignedtosupportAPMalignment.TheWorkGroup
recognizedthatimplementationmustbetailoredtomarketconduciveness,organizationalreadiness,
andthecharacteristicsofparticularinitiatives.Forthatreason,compromiseswillsometimesbe
necessarytoachievethegoalofalignment.Whencompromisesaremade,thereshouldbejustifiable
reasonsfordivergencefromtheWorkGroupsrecommendations.
TheCEPWorkGroupalsorecognizesthattherearemanyadditionalelementsthatcanbehelpfulin
deployingepisodebasedpaymentprograms.Theseincludetechnicalassistance,detailedspecification
ofcaredeliverymodels,andalignedbenefitdesigns.Whileimportant,theseelementsareoutofscope
fortheWorkGroupduetothechargefromtheLANGuidingCommitteeandthedesignatedfocusofthe
LAN.
Finally,therecommendationsandimplementationoptionsdescribedinthebodyoftheWhitePaperare
directedtowardallstakeholders.ItistheintentionoftheCEPWorkGroupthatpayers,providers,
consumers,patientsandtheirfamilycaregivers,purchasers,andstateswillallconsiderthese
recommendationsandoptionsasstartingpointsforcriticalconversationsabouthowtoworktogether
topromotealignedadoptionofepisodepaymentmodels.Specificprioritiesformovingthiswork
forwardaredescribedbelow.
MovingForward:PrioritiesforSupportingEpisodePayment
TheWorkGroupsrecommendationsincludeactionsthatarefeasibleforstakeholderstoimplementin
thecurrentenvironment;infact,manyarebasedonexistinginitiatives.Atthesametime,therearea
numberofotherareasinwhichevolutionisstillnecessaryinordertofullyoptimizetheimpactthat
APMs,ingeneral,andepisodepayment,inparticular,mayhaveonpatientsandthehealthcaresystem.
Whilethefollowinglistisnotexhaustive,thefollowingissuesstandoutasbeingnecessaryintheshort
termformovingthefieldofepisodepaymentforward:
CreatinganInfrastructurethatSupportsPersonCenteredCare:Thedesignandimplementationof
personcenteredepisodepaymentmodelsrequirestheabilityofprovidersandpatientstoengagein
shareddecisionmaking,sharedcareplanning,sharingofcriticalinformationoncostandquality,and
systematiccarecoordinationthatputsthepatientfirst.Addressingtheneedforanoverarching
infrastructurethatallowsalloftheseinteractionstooccuriscentraltosupportingepisodepayment.
TransparencyofCostData:Allstakeholdersneedtransparent,detaileddataonepisodebasedcare
pricesthatpayersnegotiatewithproviders.Havingthisdataavailableviaatrustedsourcewillallow
purchasers,payers,patients,andconsumerstomakeinformeddecisionsintheepisodepayment
process.Inaddition,informationonregionalcostvariationandonhowvariationrelatestodifferent
circumstancesisparticularlyvaluable.Ideally,participantswillbeabletocompareepisodetoFFScosts,
andunderstandcostimplicationsfortheirsituation.
ProviderandSystemReadiness:Individualprovidersmayhaveinterestinparticipatinginanepisode
paymentinitiative;however,inorderforepisodepaymenttobeeffective,itrequirescoordination
amongacollaborativecareteamthatincludesbothclinicalprovidersandpayers.Mostmarketslackthe
systemsandinfrastructuretosupportthistypeofcollaboration,andarestillhallmarkedbysiloedcare
environmentsthatdonotsharecommondataorpaymentsystems.Addressingthereadinessofboth
ApprovedforPublicRelease;DistributionUnlimited.CaseNumber162713
103
2016TheMITRECorporation.ALLRIGHTSRESERVED
providersandthesystemsinwhichtheydelivercarewillbecriticaltoeasingthepathtowardgreater
episodepaymentimplementation.
QualityMeasurement:Whiletherearemeasuresofprocessstandards,patientoutcomes,patient
engagementtools,andfunctionalstatusassessmenttoolsavailabletoday,thereareconcernsabout
howwellthesetoolssupportprovidersandpayersabilitiestoassesswhetheraproceduretruly
improvedtheoutcomeforanindividualpatient.Continueddevelopmentofkeymeasurescapableof
measuringqualityacrosssettingsofcarewillbecriticalfortheeffectivenessofepisodepayment
models.
HighValue,UnderusedServices:AsnotedinthebodyofthisWhitePaper,awidevarietyofhighvalue
services(boththosecurrentlycoveredandothersnoncovered)areunderusedtoday.Especiallywithin
maternitycare,researchsuggeststheirusecanincreasevaginalbirthrates,lowerpretermbirthrates,
andprovidenecessarysupportforchildbearingwomenandnewbornsthroughouttheepisode.There
areanumberofepisodepaymentdesignelementsthatpointtoensuringpaymentmodelsincentivize
theuseofthesehighvalue,underusedservicesacrossallepisodepaymentmodels.
LowValue,OverusedServices:Alsonotedinthispaperisthefactthatthecurrenthealthcaresystemis
overusingservicesthatdonotprovidevaluetothepatient.Theseservicesmaycomeintheformof
unnecessarydiagnosticsorprocedures.Thegoaloftheepisodesdescribedhereinistoreducethe
incentivestoprovidersforincludingthesetypesofservicesintheircareprocess,andreplacethemwith
servicesthatarehighvalue,andareappropriateforagivenpatient,basedonclinicalassessmentand
thepatientspreferencesandvalues.
104
AppendixA:Roster
CEPWorkGroupChair
LewSandy,MD
ExecutiveVicePresident,ClinicalAdvancement,UnitedHealthGroup
CEPWorkGroupMembers
AmyBassano
DeputyDirector,CenterforMedicare&MedicaidInnovation
EdwardBassin,PhD
ChiefAnalyticsOfficer,ArchwayHealth
JohnBertko
ChiefActuary,CoveredCalifornia
KevinBozic,MD
Chair,DepartmentofSurgeryandPerioperativeCare,DellMedicalSchool,theUniversityofTexasat
Austin
AlexandraClyde
CorporateVicePresident;GlobalHealthPolicy,Reimbursement,andHealthEconomics;Medtronic
BrooksDaverman
DirectorofStrategicPlanningandInnovation,DivisionofHealthCareFinanceandAdministration,State
ofTennessee
FranoisdeBrantes
ExecutiveDirector,HealthCareIncentivesImprovementInstitute
MarkFroimson,MD
ExecutiveVicePresident,ChiefClinicalOfficer,TrinityHealth
RobertLazerow
ManagingDirector,ResearchandInsights,theAdvisoryBoardCompany
CatherineMacLean,MD,PhD
ChiefValueMedicalOfficer,HospitalforSpecialSurgery
JenniferMalin,MD
StaffVicePresident,ClinicalStrategy,Anthem
CarolSakala,PhD,MSPH
DirectorofChildbirthConnectionPrograms,NationalPartnershipforWomen&Families
105
RichardShonk,MD,PhD
ChiefMedicalOfficer,theHealthCollaborative
StevenSpaulding
SeniorVicePresident,EnterpriseNetworks,ArkansasBlueCrossBlueShield
BarbaraWachsman
Chair,PacificBusinessGrouponHealth
JasonWasfy,MD
DirectorofQualityandAnalytics,MassachusettsGeneralHospitalHeartCenter
CMSAlliancetoModernizeHealthcare(CAMH)Staff
CAMH,sponsoredbyCMS,isanFFRDCoperatedbytheMITRE Corporation.MITRE ischarteredto work
inthepublicinterest.
TanyaAlteras,MPP
LANCEPWorkGroupLead
KarenMilgate,MPP
LANSubjectMatterExpert
AnneGauthier,MS
LANProjectLeader
AmyAukema,MPP
LANDeputyProjectLeader
LeahAllen
LANProjectSupport
106
AppendixB:Acknowledgements
TheCEPWorkGroupwouldliketothankthefollowingindividualsfortheirinvaluablefeedbackduring
theresearchanddevelopmentofthisWhitePaper.
PaulCasale,MD
ExecutiveDirector,NewYorkQualityCare
BoardofTrustees,AmericanCollegeofCardiology
JohnOShea,MD
CardiothoracicSurgeon
Member,SocietyforThoracicSurgeons
AndreaRusso,MD
CooperHeartInstitute,CooperUniversityHospital
Member,AmericanCollegeofCardiology
JeffreyB.Rich,MD
SentaraNorfolkGeneralHospital
PastPresident,SocietyforThoracicSurgeons(20122013)
TriciaBalazovic
AdministrativeDirector,TheMinnesotaBirthCenter
FredBuckwold,MD
SeniorVicePresident,CommunityHealthChoice
SteveCalvin,MD
MedicalDirector,TheMinnesotaBirthCenter
KarenLove
ExecutiveVicePresidentandChiefOperatingOfficer,CommunityHealthChoice
TomRaskauskas,MD
MedicalDirector,FedelisCare
Member,LANPopulationBasedPaymentWorkGroup
BrynnRubinstein
SeniorManagerforTransformingMaternityCare,PacificBusinessGrouponHealth
107
AppendixC:ElectiveJointReplacementBundledPaymentModels
Thisappendixpresentsasummaryreviewofselectedelectivejointreplacementinitiatives.Resultsreportedarebasedonstudiesofvaryingstatisticalrigorandextrapolatedfrompublications.
CMSACE
demonstration
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
MedicarePartA
andPartBservices
providedduringan
inpatientstay
AdmitsforMS
DRGs469and470
Limitedlistofservice
exclusions
Healthsystem
Prospective
Payment
Upsideand
downsiderisk
Noexplicitquality
tietopayment
methodology
NA
Medicarepayments
decreased;savingsshared
withbeneficiariesnot
accountedfor.
Limitedlistof
population
exclusions
IPandOPinan
admission,including
somepreop
Competitive
biddingbysiteson
avoluntarybasis
toprovide
orthopedic
servicesto
Medicarepatients
ininpatient
settings
Voluntarygain
sharingwith
providers
PartAandBinan
admission,including
somepreopservices
Builtindiscount
IncreaseinPartBcosts.
DischargestoPAClesslikely.
Decreaseinreadmissions.
Mixedresultson
complications.
ApprovedforPublicRelease;DistributionUnlimited.162713
108
CMSBundled
PaymentforCare
Improvement
(BPCI):Model217
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
Inpatientstay
through30,60,or
90dayspost
dischargeexcept
hospice
AdmitsforMS
DRGs469and470
Allrelatedinpatientstay
costsinacutecareand
postacutecareandall
relatedservicesfor90
dayspostdischarge
Acutecare
hospital,
physician
grouppractice,
orawardee
convener
FFSwith
retrospective
reconciliation
Reconcileactual
costagainsta
bundledpayment
amountforthe
episodeofcare,
whichisbasedon
historicalFFS
payments
Upsideand
downsiderisk
Noexplicitquality
tietopayment
methodology
NA
Earlyevaluation(basedon
onequarteronly)found:
Awardeesselect
episodelength
Limitedlistof
population
exclusionsfor
unrelatedPartB
servicesandPartA
inpatient
readmissions
AllnonhospicePartA
andPartBservices
Voluntarygain
sharingwith
providers
Increasing
upsideand
downsiderisk
overtimeto
stoplossand
stopgainlimits
Lowerlengthsofhospital
stays.
PercentageofBPCIpatients
dischargedtoan
institutionalPACprovider
(SNF,IRF,LTCH)decreased
from66%inthepreBPCI
baselineto47%during
interventionquarter.This
proportionremained
relativelysteadyat6260%
forthecomparison
hospitals.
LowernumberofHHAdays
amongpatientswithatleast
oneHHAday.
17
Note:Model1notincludedasitisadiscountoffofIPPS,notaccountabilityacrossprovidersorsettings.
109
CMSBundled
PaymentforCare
Improvement
(BPCI):Model317
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
Admissiontopost
acutecarewithin
30daysof
dischargethrough
30,60,or90days
aftertheinitiation
oftheepisode
AdmitsforMS
DRGs469and470
Providerfees(physician
andpostacutecare
services),related
readmissions,and
relatedPartBservices
(e.g.,lab,DME)
Postacute
careprovider,
providergroup
practice,or
awardee
convener
FFSwith
retrospective
reconciliation
Reconcileactual
costagainsta
bundledpayment
amountforthe
episodeofcare,
whichisbasedon
historicalFFS
payments
Upsideand
downsiderisk
Noexplicitquality
tietopayment
methodology
NA
Earlyevaluation(basedon
onequarteronly)found:
AllnonhospicePartA
andPartBservices
duringthepostacute
periodandreadmission
Voluntarygain
sharingwith
providers
Awardeesselect
episodelength
Limitedlistof
population
exclusionsfor
unrelatedPartB
servicesandPartA
inpatient
readmissions
Increasing
upsideand
downsiderisk
overtimeto
stoplossand
stopgainlimits
AveragePACdayslower
thancomparison.
Mostofdifferencewas
presentpriorto
demonstration.
HHApaymentsincreased
moreinBPCIsitesvs.
comparisonsites.
Samplewasverysmall.
CMSBundled
PaymentforCare
Improvement
(BPCI):Model417
Hipandknee
replacement
Entireacutecare
hospitalstayand
related
readmissionsfor
30days
AdmitsforMS
DRGs469and470
Limitedlistof
population
exclusionsfor
unrelatedPartB
servicesandPartA
inpatient
readmissions
Allrelatedservices
providedbythehospital,
physician,andother
practitioners
Acutecare
hospitalor
Awardee
Convener
Prospective
payment
Singlebundled
paymentforall
relatedservices
Upsideand
downsiderisk
Voluntarygain
sharingwith
providers
110
Noexplicitquality
tietopayment
methodology
NA
Resultsnotyetavailable
CMS
Comprehensive
CareforJoint
Replacement
(CJR)
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
Admissionthrough
90dayspost
dischargeforall
PartAandPartB
AdmitsforMS
DRG469and470
Limitedlistofservice
exclusions
Hospital
FFSwith
retrospective
reconciliation
Reconcileactual
spendingagainst
targetpricessetby
riskstratification
methodologyeach
year
Upsideand
downsiderisk
Payment
methodology
includes
complications,
HCAHPS,and
voluntaryreporting
ofpatientoutcome
NA
Notyetavailable.
Competitivelyset
pricethatisa
negotiated
bundledpayment
forsurgical
procedures
performedby
Centersof
Excellence
Upsideand
downsiderisk
ReplicatesCMSand
BREECollaborative
orthopedic
complication
definitionsand
measures
Patient
navigator
provides
patientsand
caregivers
with24/7
supportatthe
Centersof
Excellence
Employersavingson
procedureepisodes;
employeetravelandlodging
included.
Subjecttolimited
exclusions
PBGH
Employers
Centersof
Excellence
Network(ECEN)
withWalmart,
Lowes,
McKesson,and
JetBlue
Hipandknee
replacement
Consultation,care
andtravelthrough
postopclinical
care.
Voluntarygain
sharingwith
providers
Limitedlistof
population
exclusions
Employee
populationwilling
totraveltoa
centerof
excellencepaysno
copaysorcost
sharing;traveland
lodgingforpatient
andcaregiver
providedby
employer
SomeBMIand
other
appropriateness
criteriaappliedto
definitionof
bundleandtothe
certificationofthe
Centersof
Excellence
EpisodebasedonMS
DRG469and470
Hospital/
healthsystem
Prospective
payment
Bundleincludeshospital
charges,physicianfees,
affiliatedservices(PT,
homehealth)for710
daybundle
Increasing
upsideand
downsiderisk
overtimeto
stoplossand
stopgainlimits
Otherappropriateness
criteriaappliedto
definitionofbundleand
CentersofExcellence
certification
111
Additionally,
completionrates
andaveragechange
inHOOS/KOOSand
allincidentsof
unanticipated
medicalcare
Integrated
Healthcare
Association
aregionalhealth
care
improvement
collaborative
withseveral
healthplansand
hospitals
GeisingerHealth
System(GHS)
ProvenCareTotal
HipandTotal
Knee
Replacement
Initiatives
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Relied
primarilyon
PROMETHEUS
Evidence
basedCase
Rates(ECRs)
Admissionthrough
related
readmissions
within90daysof
hospitaldischarge.
Limitedlistof
eligiblepatientsto
avoidcomplexities
ofriskadjustment
Specificlistofservices
Hospitals
Prospective
payment
Fixed,singleprice,
coveringall
medicalcarefor
theepisode
includingphysician
fees,inpatient
stay,tests,and
devices.
Upsideand
downsiderisk
Notyet
implemented
NA
Resultsfromthestudywere
developedintoseveral
papersonimplementation
issues.(SeeAppendixF.)
Inpatient,Outpatient,
andPostAcuteCare
withsomepreoperative
careincluded
GHSfacilityor
GHSprovider
Prospective
paymentwith
retrospective
reconciliation
Setpricefor
episodeofcare
Upsideand
downsiderisk
Complications
"Patient
Compact"was
developedso
thatpatients
couldbecome
partnersin
theirown
care.
50%decreasein
readmissions.
Doesnotinclude
postacutecareas
itwouldhave
requiredmultiple
newcontracts
Hipandknee
replacement
Admissionthrough
90dayspost
discharge
AvoidhighBMI,
thosewithhigh
severityscores
Appropriateness
criteria
Limitedexclusions
basedon
prospective
provider
consensus
Readmissions
AdherencetoBest
PracticeElements
10%decreaseinlengthof
stay.
Twooftheirprograms
certifiedforexceeding
nationalbenchmarksforhip
fracturecare.
112
ArkansasHealth
Care
Improvement
Initiative
Medicaidand
commercial
payers
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
Inpatientor
Outpatient
Admissionand
PostAcuteCare
through90days
Differential
definitionsof
population
includedbasedon
thepointoftime
inthetrajectoryof
theepisode
Differentialdefinitionsof
whatservicesare
includedbasedonthe
pointoftimeinthe
trajectoryoftheepisode
Orthopedic
surgeons
FFSwith
retrospective
reconciliation
Sharedsavingsand
includesabuiltin
discountonthe
targetprice
Upsideand
downsiderisk
Readmissions
NA
Overtwoyearperiod(See
January2016reportfor
morespecifics).
Fewercases
includedinthelast
31to90days,for
example
Downsiderisk
limitedto
relativelyhigh
spendinglevels
Fewercasesincludedin
thelast31to90days,
forexample
30daywound
infection
Frequencyof
prophylaxisforDVT
andPE
ARBCBStrendforLOSfrom
2.7to2.3from2013to
1014.
Medicaid2013to2014.
TreatmentforDVT
andPE
30daywoundinfection
decreasedfrom2.0%to
1.7%.
Postopcomplications
increasedfrom8%to14%.
ProphylaxisforDVT/PE
increasedfrom13%to
17.4%
113
PROMETHEUS/H
ealthCare
Improvement
Initiative
Institute(HCI3)
Episode
Definition
EpisodeTiming
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Hipandknee
replacement
30dayspriorto
inpatientor
outpatient
admissionthrough
180dayspost
discharge
Detailedlistof
relevant,
qualifying
diagnosiscodesfor
patientinclusion
Detailedlistsof
procedurecodesfor
inclusionofservices
Variesbased
onthe
initiative;can
beeitherthe
facility,the
practice,or
both
Canuseeither
prospective
paymentor
FFSwith
retrospective
reconciliation
Prospective:
Patientspecific
predictedbudgets,
whichare
negotiatedupfront
duringcontracting
Contractscanbe
basedonupside
only,
upside/downsid
e,withor
withoutstop
loss,andwith
upsidetiedto
quality
scorecards
Buildsinsavingsfor
potentially
avoidable
complications
NA
Variesbypayerand/or
provider.
Upsideand
downsiderisk
30dayreadmission
rate
NA
Notyetavailable.
Retrospective:FFS
paymentallows
forseverity
adjustmentbased
onriskfactorsto
budgetforper
patientcosts
Tennessee
Divisionof
HealthCare
Finance&
Administration
EpisodesofCare
Hipandknee
replacement
Treatmentof
chronic
arthritis
Claimsrelatedto
totaljoint
replacement
beginning45days
priortoadmission
Procedure
Postacutecare
relatedto
procedure
Patientswithan
inpatientor
outpatienthipor
kneereplacement
procedurecode
IncludesPT,certain
medications,and
treatmentfor
complicationsdue
infections,bloodclotsor
readmissions
Orthopedic
surgeon
FFSwith
retrospective
reconciliation
Reimbursement
forepisodeisrisk
adjustedusing
historicalclaims
data
Sharedsavings
potential
Limitedbusiness,
clinical,patient,
andhighcost
outlierexclusions
Payersadjustover
timebasedonnew
data
Acceptable,
commendable,
andgainsharing
limitthresholds
areset
Upto90dayspost
discharge
Setofmeasures
evaluating
potentially
avoidable
complications
30daypost
operativeDVTorPE
90daypost
operativeinfection
rate
90daypost
operative
dislocationor
fracturerate
AverageLOS
114
AppendixD:MaternityCareBundledPaymentModels
ThisappendixpresentstheSummaryReviewofSelectedMaternityCareInitiatives.Resultsreportedarebasedonstudiesofvaryingstatisticalrigorandextrapolatedfrompublications.
Tennessee
HealthCare
Improvement
Innovation
Initiative
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
PaymentFlow EpisodePrice
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Lowrisk
pregnancy
withlive
birth
40weeksprior
todelivery
through60days
afterdeliveryor
discharge
Motheronly
Prenatal:Relatedmedical
claims,relatedmedication,
oremergencydepartment
claims
Physicianor
midwifewho
deliversthebaby
FFSwith
retrospective
reconciliation
Upsideand
Gainsharing:
Screeningratesfor
HIV,groupB
streptococcus(GBS),
cesareansection
NA
Availablelate2016
Exclusions:Various
comorbidities,
maternaldeath,
anyindicationof
leavingAMA,
triggeringevents
occurringat
FQHC/RHC,and
useofTPL
Delivery:Allclaims
GlobalBilling
Code:TaxIDof
thebilling
providerorgroup
PostpartumDays130:
NonInpatientAdmissions
(readmissions),EDclaims
notresultingin
readmission,other
pharmacy/professional/
facilityclaimswithan
inclusioncode
NoGlobalBilling
Code:TaxIDof
thebilling
providerorgroup
responsiblefor
delivery
Endofanepisode:
Costsaretotaled
andadjustedusing
ariskweightbased
on:woman'sage,
healthconditions,
andcomplications
duringpregnancy.
downsiderisk
PAP'sendofyear
averageadjusted
costiscompared
to
"Commendable"
and"Acceptable"
levelsestablished
byeachpayer.
PostpartumDays3160:
Allrelatedmedicalclaims
andmedications
Pregnancieswitha
costgreaterthan
the99.73rd
percentileafter
adjustmentand
certain
comorbidity
pregnancieswillbe
excludedfrom
PAP'sannual
averageadjusted
cost.
115
Informationalonly
(notforgainsharing):
Screeningratesfor
gestationaldiabetes,
asymptomatic
bacteriuria,hepatitisB
specificantigen,Tdap
vaccination
Arkansas
HealthCare
Payment
Improvement
Initiative
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Lowrisk
pregnancy
withlive
birth
Roughly40
weeksbefore
deliverythrough
60days
postpartum
Motheronly
Inclusions:Allprenatal
care,carerelatedtolabor
anddelivery,and
postpartummaternalcare,
includinglabs,imaging,
specialistconsultations,
andinpatientcare
Physicianornurse
midwife(provider
orprovider
group)who
deliversthebaby
andperformsthe
majorityof
prenatalcare
(identifiedby
claimswiththe
appropriate
globalOBbundle
procedure,
prenatalcare
bundle
procedure,or
officevisit
procedure)
FFSwith
retrospective
reconciliation
Upsideand
Performancemetrics
arelinkedtopayment,
butreportingmetrics
arenot.Costsavings
requireaproviderto
meetquality
thresholdsonall
performancemetrics
andreportdatafor
reportingmetrics.
NA
Medicaidcesareansection
ratereducedfrom38.6%
(baseline)to33.5%(2014),
withanestimated24%
directsavingstodate.
Exclusions:Various
comorbiditiesand
highrisk
pregnancy
Exclusions:Patientcosts
thatareincurredduring
theepisodetimeperiod
thatarenotrelatedtothe
maternityepisode
FFSpayments
duringepisode,
retrospective
adjustmentbased
uponpatient
comorbidities
downsiderisk
Provideraverage
episodecostis
comparedto
Commendable,
Acceptable,
Unacceptable
thresholdsthatare
establishedby
eachpayer
annually.When
providershave5+
episodes,an
averageepisode
costinthe
Commendable
range,andhave
metthequality
metrics,theyare
eligibletosharein
savings.For
providersthat
have5+episodes
andanaverage
costinthe
Unacceptable
range,theyshare
intherisk.
116
QualityMetrics(80%
threshold):prenatal
screeningsand
appropriateutilization
ofdiagnostictests
Performancequality
metricslinkedto
sharedsavings:HIV,
GBS,andchlamydia
screenings.
Reportingonly
metrics:gestational
diabetesscreening,
UTIorasymptomatic
bacteriuriascreening,
hepatitisBspecific
antigenscreening,and
cesareansection
utilizationrate.
Preliminaryresultsshowan
increaseinreported
screenings.From2012to
2014,chlamydiascreening
increasedfrom65%to90%
andgroupBstrepscreening
increasedfrom90%to93%.
Community
HealthChoice
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Lowrisk
andhigh
risk
deliveries
with
severity
markers
Mother:270
dayspriorto
deliverythrough
60dayspost
discharge
Motherand
newborn
Allprenatalcareand
OB/GYNsfrom
servicesrelatedtodelivery. two
multispecialty
groupproviders
whoare
Blendedcesareansection
participatingin
andvaginaldeliveryrate
thepilot
Newborn:Initial
deliverystay
andall
services/costs
upto30days
postdischarge
Exclusions:
Firstphase:
CurrentlyLevel4
NICUstay
Secondphase:
Planningonusing
individualstop/loss
limits
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
FFSwith
retrospective
reconciliation
Upsidereward
onlyinYear1
withmoveto
upsideand
Normalbirthweight:
Prenatalcareand
screenings;Delivery
care(cesareansection
rate,elective
deliveries);
Postpartumcarewith
depressionscreening;
Babycare
(breastfeeding,
hepatitisBvaccine)
Activewith
community
groupsthat
promote
prenatalcare
Usehistorical
averagecostsand
adjustbasedon
riskfactors(e.g.,
age,comorbidities,
clinicalseverity
markers).
Year1:Usequality
scorecardfor
monitoringand
setting
benchmarks.
Blendednurserylevels1,2,
and3
Exclusions:Level4NICU
stays
Downsiderisk
inYear2
Reconciliation
occursatthe
endofeach
yearofthe
pilot.
Year2:Setquality
thresholdsfor
sharedsavings.
Year3and
beyond:Move
awayfromcurrent
contractual
paymentstoflat
dollarorother
budgetpayments
with
reconciliation.
117
Lowbirthweight:
Similartoaboveplus
NICUinfectionrates
Patientreported
outcomemeasures:
Hardcopysurveyis
mailed,andresultsare
acceptedinhardcopy
oronline.
Additionalmeasures
formonitoring
purposes
Providence
Health&
Services
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Lowrisk
pregnancy
Positive
pregnancy
confirmation
until6weeks
afterdelivery
Motherand
newborn
Allprenataland
postpartumcare,including
checkups,prenataltests,
education,psychosocial
support,labor,delivery,
hospitalstay,and
postpartumcare.
Nursemidwife
Prospective
Fixed,negotiated
fee
Upsideand
NA
NA
Firstimplementationat
nursemidwifebasedclinic:
10%reductioninoverall
pregnancycostsanda
cesareansectionrateof19%
Fixedratefor
episode
Upsideand
103evidencebased
elementsofcareare
incorporated,
measured,and
trackedfor
compliance.
"Patient
Compact"was
developedso
thatpatients
couldbecome
partnersin
theirowncare.
Preliminaryresults:
Improvedinnearlyall103
measuresidentified;
reducedNICUadmissionsby
25%;23%reductioninNICU
use;26%reductionin
cesareansections;68%
reductioninbirthtrauma.
The
Pregnancy
CarePackage
Geisinger
HealthSystem
(GHS)
Perinatal
ProvenCare
Initiative
downsiderisk
Doulasandpatient
navigatorsarealso
includedservices.
Lowrisk
pregnancy
Exclusions:
Late
referrals,
highrisk
patients,
members
without
continuous
enrollment
duringthe
entire
episodeor
other
primary
coverage
Prenatal:
Identificationof
pregnancyin
thefirstor
second
trimester
Postpartum:
Concludeswith
postpartumvisit
2156dayspost
delivery
Motheronly
Exclusions:
Neonatalcare
Allprenatal,laborand
delivery,andpostpartum
care;atleast12continuous
weeksofprenatalcareand
deliverymustbe
performedbyaGHS
provider.
GHSprovider
Prospective
downsiderisk
Globalpaymentincludes
technicalandprofessional,
physician,consultations,
andsupportingclinicians
Since2011,Geisingerhas
notperformedanearly
inductionorelective
cesareanbefore41weeks
unlessmedicallyindicated.
Prenatal:Professionaland
outpatientservicesonly
Postpartum:Inpatient
readmissions,outpatient,
andprofessional
Exclusions:Careprovided
bynonGHSproviders
Nocostsavingshavebeen
madepubliclyavailableto
date.
118
Pacific
Business
Groupon
Health(PBGH)
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Highand
lowrisk
pregnancy
Hospitallabor
anddelivery
only
Motheronly
Blendedcaserateforall
facilityandprofessional
feesrenderedduringlabor
anddeliveryforboth
vaginalandcesarean
sectionbirths
Hospital
accountablefor
thefacility
blendedrate.
Prospective
Rateforcesarean
sectionandvaginal
birththesameand
negotiated
betweenpayer
andhospital,and
payerand
physiciangroup,
respectively.
Upsideand
downsiderisk
withno
prospective
risk
adjustment
Rateofcesarean
sectionsperformed
amongprimary,low
risk(NTSV)births
NA
Threehospitalsinpilot
demonstrateda20%
decreaseincesareansection
rates,whichwassustained.
Smallbirthcenters
wouldreceive
incentive
paymentsforeach
participant
providedwith
enhancedservices.
Smallbirth
centers:upside
rewardonly
PBGHBlended
CaseRate
American
Associationof
BirthCenters
(AABC)
Bundled
Payment
Proposal
Medicalgroup
practice
accountablefor
theprofessional
blendedrate.
Lowrisk
pregnancy
Enrollmentin
freestanding
birthcenter
throughand
including6
week
postpartumcare
visit
Motherand
newborncare
throughfirst28
daysoflife
Prenatalcare,nutrition,
patientnavigation,care
coordination,discussionof
optionsforbirth,
breastfeedingand
childbirthpreparation
instruction,health
educationandsupportto
avoidpreventable
complications,laborand
birthinthebirthcenter,
newborncareandhome
visits
Freestanding
birthcenter
(FSBC)
FFSwith
retrospective
reconciliation
Incidenceof
unexpectednewborn
complicationsisalso
usedasabalancing
measure.
Largebirth
centers:upside
anddownside
risk
Largebirthcenters
wouldreceivea
bundledratefor
professionaland
facilityservices
withshared
savingsforoverall
costsavings.
Largebirthcenterincludes
labservices,ultrasound,
obstetrician,andperinatal
visits
Includesfacilityfeeand
professionalfeeattimeof
birthinthebirthcenter.
119
Numberofprenatal
visits,cesareanbirth
rate,electivedelivery
before39weeks,
pretermbirthandlow
birthweightrates,
breastfeeding
initiationand
continuation,NICU
admissions,perineal
integrity,and
completionofthe6
weekpostpartumvisit
Also,nochangesin
incidenceofunexpected
newborncomplications.
Prenatal
education,
enhanced
prenatalcare,
doulas,peer
counselors,and
continuous
supportduring
laborandbirth.
Client
experience
surveys
Birthcenterstypically
achieveaveragecesarean
ratesof6%forwomen
admittedtobirthcenterin
labor,1.59%episiotomy
rate,and0.11%elective
deliveryratebefore39
weeksofpregnancy.
Baby+
Company
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Lowrisk
pregnancy
InitialOBvisitat
birthcenter
through6
weeks
postpartum
Motherand
newborn
Prenatalcare,birthingplan,
classes,postpartumcare,
newbornexam,metabolic
screen,andmedications
FSBCiflowrisk
pregnancy,
uncomplicated
delivery
FFSwith
retrospective
reconciliation
Incremental
percentageat
endofyearif
hitcertain
quality
markers
NTSVcesarean,early
electivedelivery,
exclusive
breastfeedingduring
birthcenterstay,
cesareanrateamong
womenwhoentered
laborinthebirth
center
Measuredby
loggingintoa
patientsEHRs
mirrored
interfacethat
allowsfor
patientsto
recordtheir
experiences.
Morethan90%engagement
Electronic
experience
surveysat32
weeksand
postpartum
CesareanrateforBClabors:
5.3%
Includesfacilityand
professionalfees
Workingwith
payerstoset
pricingbasedon
theoutcomes
(healthymother
andbaby)
Separatebundle
ratesiftransferred
before/during
labor
Exclusions:labs,
ultrasounds
120
NTSVrate:11.8%
Earlyelectiverate:0%
Exclusivebreastfeedingrate:
100%
The
Minnesota
BirthCenter's
BirthBundleTM
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Leveland
TypeofRisk
QualityMetrics
Patient
Engagement
Results
Lowrisk
pregnancy
270daysprior
todeliveryand
56days
postpartum
Motherand
newborn
Prenatalcare,labswithin
normalOBpanel,
ultrasound,andperinatal
consultswithinreasonable
scope,andbirth
Birthcenter
Modelis
prospectively
determined
budgetbut
paymentis
currently
retrospective
Upsideand
downsiderisk
withinthe
bundle
Patientreported
outcomemeasures
Prenatal/
postpartum
caresurveys
Resultsnotyetavailable,but
significantlylowerlevelof
cesareansectionsthanthe
nationalaverage
Positive
incentive
paymentif
averagecosts
below
Commendable
levelsand
qualitytargets
aremet
LinkedtoIncentive
Payments:HIV
Screening,GBS
Screening,cesarean
Rate,PostpartumVisit
Rate
NA
NA
Usebirthcenter
historicaldata.
Professionalfees
onlyareincludedif
deliveredina
hospital.
Facilityfee(birthcenter
only,hospitalfacilityfee
outsideofbundle)and
professionalfeeattimeof
birth
Facilityfeesare
FFSoutsideof
bundle.
Babyassessmentand
facilityfeesatdelivery
Ifallcareiswithin
thebirthcenter,
facilityand
professionalfees
areincludedinthe
bundle.
24hourpostpartum
assessment
12weekand6week
postpartumvisit
OhioEpisode
Based
Payment
Model
Lowrisk
pregnancy
withlive
birth
280daysprior
todeliveryuntil
60dayspost
delivery
Motheronly
Exclusions:specific
clinicaland
businessexclusions
Relevantprenatalcareand
complications,delivery
care,andrelevantcareand
complicationsthroughthe
postpartumperiod,
includingreadmissions
relevanttotheepisode
Physician/group
deliveringthe
baby
FFSpayment
with
retrospective
reconciliation
Riskadjusted
reimbursement
perepisodefor
eachaccountable
provider
Adjustaverage
episodecostdown
basedonpresence
of70+clinicalrisk
factors
Exclusions:prenatal
medications
Paynegative
incentiveif
121
ForReportingOnly:%
ofepisodeswith
gestationaldiabetes
screening,%of
episodeswithprenatal
hepatitisBscreening,
Episode
Definition
Episode
Timing
Patient
Population
Service
Inclusion/Exclusion
Accountable
Entity
Removalofany
individualepisodes
thataremorethan
threestandard
deviationsabove
theriskadjusted
mean
Leveland
TypeofRisk
QualityMetrics
averagecosts
areabove
Acceptable
level
%ofepisodeswith
chlamydiascreening,
ultrasoundrate
Noimpactif
averagerisk
adjustedcosts
arebetween
Commendable
andAcceptable
levels
Incentive
paymentbased
onaverage
acrossall
episodes
withina12
month
performance
period
122
Year1:qualitymetric
thresholdwillata
levelwhere75%of
providerspassall
metricstiedto
incentivepayments
AfterYear1:quality
metricthresholdwill
increasetotop
quartileperformance
overthenext5years
Patient
Engagement
Results
AppendixE:CoronaryArteryDiseaseBundledPaymentModels
ThisappendixpresentstheSummaryReviewofSelectedCABGandPCIInitiatives.Resultsreportedarebasedonstudiesofvaryingstatisticalrigorandextrapolatedfrompublications.
CABGBundled
Payment
Models
EpisodeDefinition/
Population
EpisodeTiming
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
LevelandType QualityMetrics
ofRisk
Patient
Engagement
Results
CMSBundled
Paymentsfor
Care
Improvement
(BPCI):Model
218
ElectiveandEmergent
CABG
Inpatientstay
through30,60,or
90dayspost
discharge
Allrelatedinpatientstay
costsinacutecareand
postacutecareandall
relatedservicesfor90
dayspostdischarge
Acutecare
hospital,physician
grouppractice,or
awardeeconvener
FFSwith
retrospective
reconciliation
Reconcileactual
costagainsta
bundled
payment
amountforthe
episodeofcare,
whichisbased
onhistoricalFFS
payments
Upsideand
downsiderisk
Noexplicitqualitytieto
paymentmethodology
NA
Reconcileactual
costagainsta
bundled
payment
amountforthe
episodeofcare,
whichisbased
onhistoricalFFS
payments
Upsideand
downsiderisk
paymentmethodology
NA
Awardeesselect
episodelength
CMSBundled
Paymentsfor
Care
Improvement
(BPCI):Model
318
ElectiveandEmergent
CABG
Admissiontopost
acutecarewithin
30daysof
dischargethrough
30,60,or90days
aftertheinitiation
oftheepisode
Awardeesselect
episodelength
18
AllnonhospicePartA
andPartBservices
Providerfees(physician
andpostacutecare
services),related
readmissions,and
relatedPartBservices
(e.g.,lab,DME)
AllnonhospicePartA
andPartBservices
duringthepostacute
periodandreadmission
Voluntarygain
sharingwith
providers
FFSwith
Postacutecare
provider,provider retrospective
grouppractice,or
reconciliation
AwardeeConvener
Voluntarygain
sharingwith
providers
Increasing
upsideand
downsiderisk
overtimeto
stoplossand
stopgainlimits
Increasing
upsideand
downsiderisk
overtimeto
stoplossand
stopgainlimits
Model1notincludedasitisadiscountoffofIPPS,notaccountabilityacrossprovidersorsettings
123
CABGBundled
Payment
Models
EpisodeDefinition/
Population
EpisodeTiming
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
ofRisk
Patient
Engagement
Results
CMSBundled
Paymentsfor
Care
Improvement
(BPCI):Model
418
ElectiveandEmergent
CABG
Entireacutecare
hospitalstayand
related
readmissionsfor
30days
Allrelatedservices
providedbythe
hospital,physician,and
otherpractitioners
Acutecare
hospitalor
awardeeconvener
Prospective
payment
Singlebundled
paymentforall
relatedservices
Upsideand
downsiderisk
paymentmethodology
NA
GeisingerHealth
System(GHS)
CABG
ProvenCare
Initiative
ElectiveCABG
Prospective
Payment
Setpricefor
episodeofcare.
Upsidereward
40+bestpracticeprocess
measures
Engage
patientswith
postdischarge
servicessuch
ashome
health
servicesand
cardiacrehab
Clinicaloutcomeimprovements
showadecreaseininhospital
mortality,patientswithany
complications(STS),atrial
fibrillation,permanentstroke,
prolongedventilation,re
intubation,intraopblood
productsused,reoperationfor
bleeding,deepsternalwound
infection,andpostopmeanLOS
Voluntarygain
sharingwith
providers
Procedurethrough
90dayspost
discharge
Preoperative
evaluation,allhospital
andprofessionalfees,
routinepostdischarge
care,andmanagement
ofrelatedcomplications
occurringwithin90days
ofprocedure
GHSfacilityorGHS
provider
Singlepayment
tothehospital
systemand
singlepayment
totheprovider
system
(paymenttothe
provider/surgeo
nisallocatedto
multipleservice
lines/providers
encounters)i.e.,
CABGsurgery,
anesthesiology,
cardiology
124
Developeda
Patient
Compact
Hospital:Contributionmargin
increased17.6%,andtotal
inpatientprofitpercaseimproved
$1,946
HealthPlan:Paid4.8%lessper
caseforCABGwithProvenCare
thanitwouldhavewithout;paid
out28to36%lessforCABGwith
GHSthanwithotherproviders
CABGBundled
Payment
Models
EpisodeDefinition/
Population
EpisodeTiming
Service
Inclusion/Exclusion
Accountable
Entity
Payment
Flow
EpisodePrice
ofRisk
Patient
Engagement
Results
PROMETHEUS/
HealthCare
Improvement
Initiative
Institute(HCI3)
ElectiveandEmergent
CABG
30dayspre
admissionthrough
180dayspost
discharge
Detailedlistsof
procedurecodesfor
inclusionofservices
Variesbasedon
theinitiative;can
beeitherthe
facility,the
practice,orboth
Canuseeither
prospectiveor
FFSwith
retrospective
reconciliation
Prospective:
Patientspecific
predicted
budgets,which
arenegotiated
upfrontduring
contracting
Contractscanbe
basedonupside
rewardonly,
upsideand
downsiderisk,
withorwithout
stoploss,and
withupside
rewardtiedto
quality
scorecards
Setofmeasuresevaluating
potentiallyavoidable
complications
NA
NA
Upsideand
downsiderisk
Averagelengthofpre
operativeinpatientstay
NA
Retrospective:
FFSpayment
allowsfor
severity
adjustment
basedonrisk
factorsto
budgetforper
patientcosts
ArkansasHealth
CarePayment
Improvement
Initiative
AcuteandNonacute
CABGProcedure
EmergencyCABG
excluded
Dateofsurgery
through30days
postdischarge
fromfacilitywhere
surgeryoccurred
Allrelatedinpatient,
outpatient,professional,
andpharmacyservices
happeningwithinthe
episodetimeframe
Physician
performingthe
CABG
FFSwith
retrospective
reconciliation
Exclusion:PCI
convertingtoCABG
within1day
Averagecost
perepisodefor
each
accountable
provideris
comparedto
commendable
andacceptable
levels
Percentofpatientsadmitted
ondayofsurgery
Percentofpatientsfor
whomaninternalmammary
arteryisused
125
AppendixF:ElectiveJointReplacementImplementationResources
GeneralResources:
CentersforMedicare& ThewebpagefortheBundledPaymentforCareImprovement(BPCI)
MedicaidServices(CMS) modelsincludesdetailsonepisodedefinitions,eligibleMSDRGs,andlists
BundledPaymentfor
ofparticipantsinthemodel.
CareImprovement
(BPCI)HomePage
IntegratedHealthcare
Association(IHA)
BundledPaymentsWeb
Page
TheIHAwebsiteoffersmultiplereportsandspecificationdocumentson
bundledpayments.
ArkansasHealthCare
ImprovementInitiative
PaymentReforms
Report
TheArkansasHealthCareImprovementInitiativereportdescribesthat
state'spaymentreforms,includingtheirepisodesofcarework.
Descriptionofthedesignandfindingsfromtheirinitiativeareincluded.
Medicaidandseveralinsurers,includingBlueCrossBlueShieldof
Arkansas,aredescribedindetail.
StateofTennessee
HealthCareInitiative
EpisodesofCare
Descriptionand
Examples
TheStateofTennesseeHealthCareInitiativewebsiteoffersdescriptions
ofepisodesofcareandexamplesofqualityandcostproviderreports.
HorizonBlueCrossBlue
ShieldinNewJersey
Payer
andProvider
RelationshipCaseStudy
TheHorizonBlueCrossBlueShieldinNewJerseycasestudyincludes
resultsandadescriptionoftheincentiverelationshipbetweenthepayer
andprovider.
PacificBusinessGroup
onHealth(PBGH)
EmployeeCenterof
ExcellenceNetwork
(ECEN)Summary
ThePacificBusinessGrouponHealthoffersanEmployersCenterof
ExcellenceNetworkinwhichcertainhospitalsandhealthsystemsare
designatedCentersofExcellence.Thesecentersagreetotakeabundled
paymentfortheepisode,andseverallargeemployersprovideincentives
toemployeeswhoneedthoseservicestoseekcarefromthecenters
providers.
126
EpisodeDefinition:
HealthCareIncentives
ImprovementInstitutes
EvidenceBasedCase
RatesandDefinitions
TheHealthCareIncentivesImprovementInstitutewebsiteprovidesopen
sourcedefinitionsofvariousevidencebasedcaserates.Includesspecific
codesthatcanbeusedfordefiningthetriggereventandwhatservices
areincluded.
TheIntegratedHealthcareAssociationsdescriptionofdefinitionsofthe
episodeoffersaprototypeusedbyseveralpayersandproviders,
Associations
Description
particularlyinCalifornia.
ofEpisodeDefinitions
CentersforMedicare&
MedicaidServices(CMS)
BundledPaymentfor
CareImprovement
(BPCI)Program
Presentation
ThisCMSpresentationontheBundledPaymentforCareImprovement
modelsincludesinformationonhowtodefineepisodesincludingdataon
episodecostsandpostacutecareusevariation.
CatalystforPayment
Reform(CPR)
Reporton
ImplementingTotalJoint
ReplacementEpisode
PaymentHowtoGuide
TheCatalystforPaymentReformreportonimplementingtotaljoint
replacementepisodepaymentisadownloadabledocumentthatincludes
aspreadsheetwithseveralexamplesofinclusionandexclusionlistsas
wellasguidanceonthestepsnecessary,includinginitialdataanalysis,
modelcontractlanguage,andstakeholderexpectations.
SharedDecisionMakingTools:
SharedDecisionMakingforTotal
JointReplacement:
ThePhysicians
Role
SharedDecisionMakingforTotalJointReplacement:The
PhysiciansRole,publishedbytheRheumatologyNetwork,
containsdescriptionofconsiderationsinshareddecision
makinganddeterminationsofwhentotaljointreplacement
ismosteffective.
ThisHealthAffairsarticlecitesevidenceoftheimpactof
Introducing
DecisionAids
atGroup
HealthwasLinkedtoSharplyLower
decisionaidsonthecostsanduseoftotaljointreplacement.
Hip
andKneeSurgeryRatesandCosts
DecisionAidLibraryInventory(DALI)
TheDALIwebsitecontainsaninventoryofdecisionaidtools
thatmeetthecriteriaoftheInternationalPatientDecision
AidStandards(IPDAS)Collaboration.Theinventoryisan
Excelspreadsheetthatprovidesthetreatmentareaandlinks
tothesponsoringorganization.
127
PatientAssessmentTools:
KneeInjury
andOsteoarthritis
OutcomeScore(KOOS)
TheKOOSquestionnairewasdevelopedasaninstrumenttoassess
thepatientsopinionabouttheirkneeandassociatedproblems.
ThepsychometricpropertiesoftheKOOShavebeenassessedin
morethan20individualstudiesfromallovertheworld.KOOSis
widelyusedforresearchpurposesinclinicaltrials,largescale
databases,andregistries.KOOSisalsoextensivelyusedforclinical
purposes.Itconsistsof5subscales:pain,othersymptoms,
functionindailyliving,functioninsportandrecreation,andknee
relatedqualityoflife.
HOOSwasdevelopedasaninstrumenttoassessthepatients
Hip
DisabilityandOsteoarthritis
opinionabouttheirhipandassociatedproblems.HOOSis
OutcomeScore(HOOS)
intendedtobeusedforhipdisabilitywithorwithoutosteoarthritis
(OA).HOOSismeanttobeusedoverbothshortandlongtime
intervals;toassesschangesfromweektoweekinducedby
treatment(medication,operation,physicaltherapy)oroveryears
duetotheprimaryinjuryorposttraumaticOA.HOOSconsistsof5
subscales:pain,othersymptoms,functionindailyliving,function
insportandrecreation,andhiprelatedqualityoflife.
PatientReportedOutcome
MeasurementInformation
System(PROMIS)
PROMISinstrumentsusemodernmeasurementtheorytoassess
patientreportedhealthstatusforphysical,mental,andsocial
wellbeingtoreliablyandvalidlymeasurepatientreported
outcomes(PROs)forclinicalresearchandpractice.PROMIS
instrumentsmeasureconceptssuchaspain,fatigue,physical
function,depression,anxiety,andsocialfunction.Whilenot
specificallydesignedforoutcomesrelatedtohipandknee
replacement,itdoesincludeabroadersetofoutcomesthanthe
KOOSandHOOS,includingmentalfunctioningandqualityoflife.
VeteransRAND12ItemHealth
Survey(VR12)
The12ItemShortFormHealthSurvey(SF12)wasdevelopedfor
theMedicalOutcomesStudy,amultiyearstudyofpatientswith
chronicconditions.Thesequestionnaireshelpaninvestigatoror
cliniciangatherreliableinformationaboutpatienthealth,save
timeandmoneyinobtainingthisinformation,obtaininformation
thatcouldnototherwisebeobtained,determinetheeffectiveness
ofalternativetreatments,andassessthecourseofhealthover
time.A20Itemand36Itemsurveyisalsoavailable.
QualityMeasurement:
NationalQualityForum
TheNationalQualityForum(NQF)leadsnationalcollaborationto
improvehealthandhealthcarequalitythroughmeasurement,
primarilythroughmeasureendorsement.NQFoverseestheQuality
PositioningSystem,asearchabledatabaseofqualitymeasures.
128
QualityMeasurement:
CMSMeasuresInventory
TheCMSMeasuresInventoryisacompilationofmeasuresusedby
CMSinvariousquality,reportingandpaymentprograms.The
Inventorylistseachmeasurebyprogram,reportingmeasure
specificationsincluding,butnotlimitedto,numerator,denominator,
exclusioncriteria,NationalQualityStrategy(NQS)domain,measure
type,andNationalQualityForum(NQF)endorsementstatus.
HospitalCompare
HospitalCompareoffersinformationaboutthequalityofcareatover
4,000Medicarecertifiedhospitalsacrossthecountry,including:
Hospitallevelriskstandardizedcomplicationrate(RSCR)following
electiveprimarytotalhiparthroplasty(THA)and/ortotalknee
arthroplasty(TKA)(NQF#1550)
Hospitallevel30dayallcauseriskstandardizedreadmissionrate
(RSRR)followingelectiveprimarytotalhiparthroplasty(THA)
and/ortotalkneearthroplasty(TKA)(NQF#1551)
CoreQualityMeasures
Collaborative(CQMC)
AmericasHealthInsurancePlans(AHIP),togetherwithCMSandthe
NQF,convenestheCoreQualityMeasuresCollaborative(CQMC),
whichiscomprisedofleadersfromhealthplans,physicianspecialty
societies,employersandconsumers.TheCQMCworkstodevelop
consensusdrivencoremeasuresetsacrossavarietyofclinicalareas,
includingorthopedics,withthegoalofharmonizingimplementation
acrossbothcommercialandgovernmentpayers,whichwill,inturn,
supportqualityimprovementefforts,reducethereportingburdenof
qualitymeasures,andofferconsumersactionableinformationfor
decisionmaking.
CMMIComprehensiveCare
forJointReplacement
Mode:QualityMeasures,
VoluntaryData,Public
ReportingProcessesfor
PreviewReports
Thisdocumentincludesinformationonariskadjustedsetoftotaljoint
replacementoutcomemeasuresthatarebeingusedbyCMSand
providersaspartoftheCJRprogram.
129
AppendixG:MaternityCareImplementationResources
ExistingInitiatives
StateofTennesseeHealth
CareInitiative
Episodesof
Care
DescriptionandExamples
ArkansasHealthCare
PaymentReformReport
CommunityHealthChoice
MaternityandNewborn
CareBundledPayment
Pilot
TheStateofTennesseeHealthCareInitiativewebsiteoffers
descriptionsofdifferentepisodesofcareandexamplesofqualityand
costreportingfromproviders.
TheArkansasHealthCareImprovementInitiativereportdescribesthe
statespaymentreforms,includingitsepisodepaymentwork.
Descriptionoftheepisodedesignandfindingsfromitsinitiativeare
included.TherolesofMedicaidandseveralinsurers,includingBlue
CrossBlueShieldofArkansas,aredescribedindetail.
CommunityHealthChoicespilotincludesboththemotherand
newbornintheepisodeofcareandusesablendedcesareanand
vaginaldeliverypaymentrate.
ProvidenceHealths
PregnancyCarePackage
ProvidenceHealthsPregnancyCarePackageusesabundledpayment
modelthatincludestheuseofcertifiednursemidwives,patient
navigators,anddoulasonthecareteam.
Geisingers
Perinatal
ProvenCareInitiative
GeisingerusestheProvenCaremodeltoprovideaglobalpaymentfor
theperinatalepisodeandallowsproviderstoshareinsavings.
PacificBusinessGroupon
Health(PBGH)
ThePacificBusinessGrouponHealthdesignedapilotprogramto
reducelowrisk,firsttimecesareandeliveriesandimplementedthis
programacrossthreeSouthernCaliforniaHospitals.
MaternityPaymentand
CareRedesignPilotCase
Study
Baby+Company
Baby+Companyisabirthcentermodelthatprovidesenhancedprenatal
careandeducationtoreducetherateofcesareandeliveries,andshows
significantsavingsincostforbothvaginalandcesareandeliveries.The
Baby+Companywebsiteoffersadditionaldetailsaboutthebirthcenter.
TheMinnesotaBirth
CentersBirthBundleTM
TheMinnesotaBirthCentersBirthBundleTMprovidescostsavingsby
offeringasingle,globalfeeformaternitycare.Itusescertifiednurse
midwiveswhocollaboratewithOBphysicianstoprovidecoordinated
clinicalcarethroughoutthepregnancy,delivery,andpostpartum
period.
OhioHealth
Transformation
TheOhioGovernorsOfficeofHealthTransformationwebsiteoffers
informationonitsimplementationofepisodebasedpaymentmodels.
EpisodeBasedPayment
Model
130
GeneralResources:
Associations
Description
of
MaternityandWomens
HealthEpisodeDefinitions
TheIntegratedHealthcareAssociationsdescriptionoftheMaternity
andWomensHealthEpisodesdefinitionsoffersaprototypeusedby
severalpayersandproviders,particularlyinCalifornia.
(HCI3)
EvidenceBasedCase
RatesandDefinitions
TheHealthCareIncentivesImprovementInstitute(HCI3)website
providesopensourcedefinitionsofvariousevidencebasedcase
rates.Includesspecificcodesthatcanbeusedfordefiningthe
episodestartingpointandwhatservicesareincluded.
CatalystforPayment
Reform(CPR)
Maternity
CarePayment
ActionBrief
TheCatalystforPaymentReformissuebriefonmaternitycare
paymentdiscusseschallengeswithmaternitypaymentreform,offers
advicetopurchasers,anddefinesblendedpaymentfordelivery.
CenterforHealthcare
Quality
&PaymentReform
(CHQPR)
TheCHQPRwebsiteoffersvariouspublicationsandreportsdetailing
suggestionsforpaymentreform.
Overdue:Medicaidand
PrivateInsuranceCoverage
ofDoulaCaretoStrengthen
MaternalandInfantHealth
TheNationalPartnershipforWomen&Families,Childbirth
Connection,andChoicesinChildbirthworkedtogetheronthisissue
brief,whichprovidesadditionaldetailsonhowdoulaservicescanbe
incorporatedintoaperinatalepisodeofcaretohelpreducethecost
ofanepisode.
AmericanAssociationof
BirthCenters(AABC)
TheAABCwebsiteprovidescomprehensiveinformationontheroleof
birthcentersinmaternitycare,includingaproposalrelatedtousing
alternativepaymentmodelsformaternitycare.
NationalAssociationof
CertifiedProfessional
Midwives(NACPM)
TheNACPMoffersaproposaltoaddressthedefinitionoftheeligible
population,threepaymentmodels,qualitymetrics,anddata
collectionformaternitybundles.
BundledPaymentProposal
131
PatientEngagement:
ChildbirthConnection
Resultsfromanationalsurveyofwomenschildbearingexperiences.
Listening
toMothersIII:
PregnancyandBirth
Childbirth
Connection
Resultsfromanationalsurveyofwomenschildbearingexperiences.
Listening
toMothersIII:
NewMothersSpeakOut
SupportforHealthy
BreastfeedingMothers
andHealthyTermBabies
TheCochraneLibraryprovidesadiscussionontheeffectivenessof
encouragingearlyandongoingsupportforbreastfeeding.
USOpenNotesInitiative
Thisinitiativeallowspatientstoaccesstheirprovidersclinicalnotes
online.
MaternityNeighborhood
Toolsavailableonlinetohelpconnectwomenwiththeirproviders
duringtheirperinatalepisodes.
StrongStartInitiative
Resultsfrombothyear1andyear2oftheStrongStartforMothersand
NewbornsInitiative.
Year 1 AnnualReport
Year2AnnualReport
CenteringPregnancy
ThiswebsiteoffersadditionalinformationonCenteringPregnancys
groupcareandeducation.
InformedMedical
DecisionsFoundation
HealthWiseResearchandAdvocacyprovidesinformationforpatients
toparticipateinashareddecisionmakingprocessoftheirhealthcare.
PatientDecisionAids
Anonlineinventoryofdecisionaidsbytopicthathavebeenrated
accordingtointernationalstandards.
QualityMeasurement:
CoreQualityMeasure
Collaborative(CQMC)
AmericasHealthInsurancePlans(AHIP),togetherwithCMSandthe
NQF,convenestheCoreQualityMeasuresCollaborative(CQMC),
whichiscomprisedofleadersfromhealthplans,physicianspecialty
societies,employers,andconsumers.TheCQMCworkstodevelop
consensusdrivencoremeasuresetsacrossavarietyofclinicalareas,
includingorthopedics,withthegoalofharmonizingimplementation
acrossbothcommercialandgovernmentpayers.This,inturn,will
supportqualityimprovementefforts,reducethereportingburdenof
qualitymeasures,andofferconsumersactionableinformationfor
decisionmaking.
132
QualityMeasurement:
TheNationalQualityForum(NQF)leadsanationalcollaborationto
improvehealthandhealthcarequalitythroughmeasurement,
primarilythroughmeasureendorsement.NQFoverseestheQuality
PositioningSystem,asearchabledatabaseofqualitymeasures.
TheCMSMeasuresInventoryisacompilationofmeasuresusedby
CMSinvariousquality,reporting,andpaymentprograms.The
Inventorylistseachmeasurebyprogram,reportingmeasure
specificationsincluding,butnotlimitedto,numerator,denominator,
exclusioncriteria,NationalQualityStrategy(NQS)domain,measure
type,andNationalQualityForum(NQF)endorsementstatus.
HealthyPeople2020
ThiswebsiteprovidesinformationonvariousHealthPeoplequality
initiativesformaternal,infant,andchildhealth.
AmericanCongressof
Obstetriciansand
Gynecologists(ACOG)
ACOGprovidesguidelinesthataddressareaswherequality
improvementinitiativesmayprovidepositiveoutcomesforthe
motherandinfantduringaperinatalepisode.
QualityImprovementin
MaternityCare
CentersforMedicare&
ThisCMSwebsiteprovideslinkstovariousdataandmeasurement
materialrelatedtomaternalandinfantcare.
MaternalandInfantHealth
CareQuality
BetterMeasurement of
MaternityCareQuality
ThisblogbyHealthAffairsdiscussesvariationsinratesofobstetrical
complicationsacrossthenationandoffersstepsthatmayhelp
cliniciansbecomemoreawareofqualitymeasures.
133
AppendixH:CoronaryArteryDiseaseImplementationResources
ExistingInitiatives
CentersforMedicare&
BundledPaymentforCare
Improvement(BPCI)Home
Page
ThewebpagefortheBundledPaymentforCareImprovement(BPCI)
modelsincludesdetailsonepisodedefinitions,eligibleMSDRGs,and
listsofparticipantsinthemodel.
BlueCrossBlueShieldof
Texas
BlueCrossBlueShieldofTexascreatedaBlueCareConnectionprogram
foritsmemberstobettercontrolchronicconditions.
NewYorkStateDelivery
SystemReformIncentive
Payment(NYEDSRIP
Program)
TheNewYorkStateDeliverySystemReformIncentivePayment
Programisoneexampleofaframeworkthatpaysfromthecondition
perspectiveinsteadofbyprocedure.
GeisingersProvenCare
Initiative
GeisingerusestheProvenCaremodeltoprovideaglobalpaymentfor
PCIandCABGproceduresandallowsproviderstoshareinsavings.
EvidenceBasedCaseRates
andDefinitions
TheHealthCareIncentivesImprovementInstitutewebsiteprovides
opensourcedefinitionsofvariousevidencebasedcaserates.This
includesspecificcodesthatcanbeusedfordefiningthetriggerevent
andwhatservicesareincluded.
StateofTennesseeHealth
CareInitiative
TheStateofTennesseeHealthCareInitiativewebsiteoffers
descriptionsofepisodeofcareandexamplesofqualityandcost
providerreports.
EpisodeofCare
DescriptionandExamples
OhioHealth
Transformation
EpisodeBasedPayment
Model
ArkansasHealthCare
PaymentReformReport
TheOhioGovernorsOfficeofHealthTransformationwebsiteoffers
informationontheirimplementationofepisodebasedpayment
models.
TheArkansasHealthCareImprovementInitiativereportdescribesthe
statespaymentreforms,includingtheirepisodepaymentwork.
Descriptionofthedesignandfindingsfromtheirinitiativeareincluded.
TherolesofMedicaidandseveralinsurers,includingBlueCrossBlue
ShieldofArkansas,aredescribedindetail.
134
GeneralResources
ConvenerOrganizations
ExamplesofconvenerorganizationsincludePremier,Inc.,which
primarilyworkswithhospitals,andCogentHealthcare,whichmanages
hospitalistpractices.
HealthCareSystem
FederalLaws
ThisresourceguideprovidesfurtherinformationontheAntiKickback
StatuteandTheCivilMonetaryPenaltiesLaw.Furtherinformationon
theSelfReferralLawcanbefoundhere.
CMSAcuteCareEpisode
(ACE)Demonstration
Thisbundledpaymentapproachincludes28cardiacand9orthopedic
inpatientsurgicalservicesandprocedures.
PhysicianEngagement
TheInformedMedical
DecisionsFoundations
PatientVisitGuide
TheInformedMedicalDecisionsFoundationprovidesaPatientVisit
Guidetohelppatientsaskquestionsandworkwiththeirdoctorsto
makefullyinformeddecisionsregardingtheirhealthcare.
AgencyforHealthcare
ResearchandQuality
(AHRQ)EffectiveHealth
CareProgram
AHRQsEffectiveHealthCareProgramprovidesadditionalresourcesfor
patientstounderstandtheirconditionandstarttheconversationwith
theirproviderregardingtreatmentoptions.
DecisionAidLibrary
Inventory(DALI)
TheDALIwebsitecontainsaninventoryofdecisionaidtoolsthatmeet
thecriteriaoftheInternationalPatientDecisionAidStandards(IPDAS)
Collaboration.TheinventoryisanExcelspreadsheetthatprovidesthe
treatmentareaandlinkstothesponsoringorganization.
CardiovascularDisease
RiskCalculator
Thisriskassessmenttoolpredictsapatientsriskofhavingaheart
attackinthenexttenyears.
NewcastleHospitalPatient NewcastleHospitalssectiononshareddecisionmakingprovidesa
shortvideo,fromtheMAGICProgramme,onthethreemostimportant
andVisitorGuides
questionstoaskyourhealthcareproviderwhenmakingadecision.This
sectionalsoprovidesmoreinformationontheneedforpatientstobe
involvedindecisionsabouttheirhealthcare.
HealthConsumerAlliance
TheHealthConsumerAlliancehasdevelopedawebsitethatlinksto
variousconsumerbrochureswhichanswerfrequenthealthcare
questions,includingtheKnowYourRightsFactSheet.
JointCommissionsSpeak
UpTMProgram
BrochuresandvideosareavailableonTheJointCommissionswebsite
asapartoftheirnationalpatientsafetycampaigncalledSpeakUpTM.
135
PhysicianEngagement
MayoClinicStudy
CardiacRehabilitation
mobileapp
SMARTCarePilot
TheMayoClinicstudiedtheeffectofusingamobileapptohelp
encouragecardiacrehabilitationforpatientswhorecentlysufferedan
episodeofacutecoronarysyndrome.
Thispilotproject,developedbytheFloridaandWisconsinchaptersof
theAmericanCollegeofCardiologyaimstoimprovequalityofcare,
enhanceaccesstocare,andreducehealthcarecostsbyprovidingtools
tohelpphysiciansandcardiovascularteammembersapplyguidelines
andappropriateusecriteria(AUC)atthepointofcare.
PatientReportedOutcome PROMISinstrumentsusemodernmeasurementtheorytoassess
MeasurementInformation patientreportedhealthstatusforphysical,mental,andsocialwell
beingtoreliablyandvalidlymeasurepatientreportedoutcomes(PROs)
System(PROMIS)
forclinicalresearchandpractice.PROMISinstrumentsmeasure
conceptssuchaspain,fatigue,physicalfunction,depression,anxiety,
andsocialfunction.
CareTransitions
AcuteCareforElders(ACE) TheUniversityHospitalsCaseMedicalCenterdevelopedtheAcuteCare
forEldersmodelofcaretoassistwiththetransitionfromaninpatient
Program
admissiontohomeforelderlypatients.
CareTransitions Coaching
Program
AprogramattheUniversityofColoradowhichusesTransition
Coachestoteachskillstopatientsandcaregiverstopromoteand
supportcontinuityofcare.
H2HHospitaltoHome
QualityInitiative
TheAmericanCollegeofCardiology(ACC)andtheInstitutefor
HealthcareImprovement(IHI)createdthisinitiativetoprovide
resourcesforthetransitionofthepatientfromthehospitaltothe
patientshome
QualityMeasurement
AmericanCollegeof
Cardiology(ACC)
AppropriateUseCriteria
andTreatmentGuidelines
ThiswebsiteprovidesadditionalinformationaboutTheAmerican
CollegeofCardiologysAppropriateUseCriteriaandTreatment
Guidelines.
SocietyofThoracic
SurgeonsQuality
PerformanceMeasures
Thiswebsiteliststhecardiacrelatedqualitymeasuresthatare
developedandmaintainedbytheSocietyofThoracicSurgeons.
136
QualityMeasurement
CoreQualityMeasures
Collaborative(CQMC)
TheCoreQualityMeasuresCollaborativecreatedaConsensusCoreSet
forCardiovascularMeasures.
TheNationalQualityForum(NQF)leadsnationalcollaborationto
improvehealthandhealthcarequalitythroughmeasurement,primarily
throughmeasureendorsement.NQFoverseestheQualityPositioning
System,asearchabledatabaseofqualitymeasures.
TheCMSMeasuresInventoryisacompilationofmeasuresusedbyCMS
invariousquality,reporting,andpaymentprograms.Theinventorylists
eachmeasurebyprogram,reportingmeasurespecificationsincluding,
butnotlimitedto,numerator,denominator,exclusioncriteria,National
QualityStrategy(NQS)domain,measuretype,andNationalQuality
Forum(NQF)endorsementstatus.
HospitalCompare
HospitalCompareoffersinformationaboutthequalityofcareatover
4,000Medicarecertifiedhospitalsacrossthecountry.
137
AppendixI:LANRelatedContent
InadditiontotheCEPWorkGroup,theLANGuidingCommitteeconvenedtwoadditionalWorkGroups
thatproducedcontentrelevanttomanyreadersofthisWhitePaper.
TheAlternativePaymentModel(APM)FrameworkandProgressTrackingWorkGroupproducedthe
AlternativePaymentModelFramework,whichdescribesfourcategoriesofalternativepaymentmodels.
ThePopulationBasedPaymentWorkGroupdevelopedrecommendationsfortheimplementationof
populationbasedpayment,withafocusonfourpriorityareas:financialbenchmarking,patient
attribution,performancemeasurement,anddatasharing.
ThesepriorityareasshouldbeconsideredasawholeforeffectivePBPimplementationastheyinteract
considerably.Forexample,todeterminethefinancialbenchmark,itiscriticaltoknowpreciselywhich
patientsarebeingattributedtothePBPmodel.Further,mostPBPinitiativeswillrequireperformance
oncertainmeasuresinconsideringwhethertheaccountableentityhasmetthebenchmark.Data
sharingiscriticalfortheproviderstoeffectivelytargettheirefforts,forpayersandpurchasersto
monitorperformanceandforpatientstobeempoweredtobeactiveintheircare.
ThefollowingprovideslinksandabriefoverviewofeachofthepaperswrittenbytheAPMandPBP
WorkGroups.Theseproductsofferreadersofthispaperadditionalresourcestosupportdecision
makingonAPMdesignandimplementation.Visitourwebsite(https://www.hcplan.org)foranupto
datelistofLANworkproductsandforaglossaryofterms.
TheAlternativePaymentModelFrameworkWhitePaper
TheAPMFrameworkWhitePaperdefinespaymentmodelcategoriesandestablishesacommon
frameworkandasetofconventionsformeasuringprogressintheadoptionofAPMs,whichare
methodsofrewardinghealthcareprovidersbasedonthequalityandcoordinationofthecarethey
provide.Providersareencouragedtomovetocategoriesthatoffergreaterqualityandvalue.Asthey
do,theywillexperienceincreasedaccountabilityforbothqualityofcareandtotalcostofcare,witha
greaterfocusonpopulationhealthmanagement(asopposedtopaymentforspecificservices).
AcceleratingandAligningPopulationBasedPayment:FinancialBenchmarking
TheFinancialBenchmarkingWhitePaperdescribesapproachesforsettinganinitialbenchmarkand
updatesovertimeandalsoaddressesriskadjustmentconsiderations.TheWhitePaperdiscussesthe
needtobalancevoluntaryparticipationwiththemovementtowardconvergenceinamarketwith
providersatdifferentstartingpoints.
AcceleratingandAligningPopulationBasedPayment:PatientAttribution
ThePatientAttributionWhitePaperdescribesthemethodbywhichpatientpopulationsareassignedto
providerswhoareaccountablefortotalcostofcareandqualityoutcomesfortheirdesignated
populationsinaPBPmodel.Thepaperrecommendsthatactive,intentionalidentificationorself
reportingbypatientsshouldbeconsideredfirst.Thepaperalsooutlinesnineadditional
recommendationsthatpayersandproviderscanusewhenmakingdecisionsonattributionintheirPBP
models.
AcceleratingandAligningPopulationBasedPayment:PerformanceMeasurement
ThePerformanceMeasurementWhitePaperoffersbothshorttermactionrecommendationsanda
longertermvisionforacceleratingalignmentaroundAPMs.Thepaperoffersawayforwardthatcould
138
leadtoradicalchangeinhowperformanceismeasuredacrosstheboardinordertoenableeffective
populationbasedpayments.TheWhitePaperdescribeshowtoevolvefromgranularmeasurement
systemsofthefullcontinuumofcare,whichfocusonnarrowandspecificcareprocesses,tomore
macrolevelmeasurementsystemsorientedonoutcomes.Thepaperalsomakesstrong
recommendationsforimmediateactionstepsbydescribingfourkeyperformancemeasurement
principlesandsevenrecommendationsforbuildingandsustainingaperformancemeasurementsystem
thatsupportsandencouragescollaborationamongstakeholders.
AcceleratingandAligningPopulationBasedPayment:DataSharing
TheDataSharingWhitePaperoffersseveralguidingprinciplesandrecommendationsthathighlightthe
futuredevelopmentofdatasharingarrangementsinPBPmodels.ThepaperalsooutlinesUseCasesfor
datasharingwhichdescribeparticulartypesofdatasharingarrangements,inboththeircurrentand
aspirationalstates.Thegoalistocreateanenvironmentwheredatafollowsthepatientandisavailable
tostakeholders(patients,providers,purchasers,andpayers)inatimelymanner.
139
AppendixJ:PrinciplesforPatientandFamilyCenteredPayment
Thefollowingprinciples,producedbytheLANsConsumerandPatientAffinityGroup,areintendedto
helpguidethedevelopmentofnewpaymentstrategies.Theyprovideguidanceandaspirational
directiontoensurethatweaddresstheneedsandprioritiesofpatientsandfamiliesaswetransitionto
valuebasedpayment.Theprinciplesrestontheconvictionthatconsumers,patients,andfamiliesare
essentialpartnersineveryaspectoftransforminghealthcareandimprovinghealth.
Consumers,patients,familiesandtheiradvocatesshouldbecollaborativelyengagedinallaspectsof
design,implementation,andevaluationofpaymentandcaremodels,andtheyshouldbeengagedas
partnersintheirowncare.
Thecollaborationindesignofpaymentandcaremodelsshouldincludeoversight,governance,and
interfacewiththecommunitieswherecareisdelivered.Atthepointofcare,patientsandfamilies
shouldbeengagedinwaysthatmatchtheirneeds,capacitiesandpreferences.Collaborativecareshould
bealignedwithpatientgoals,valuesandpreferences(includinglanguage),andshouldreflectshared
careplanninganddecisionmakingthroughoutthecarecontinuum.
Positiveimpactonpatientcareandhealthshouldbeparamount.
Thecentralconsiderationinallpaymentdesignshouldbeimprovingpatienthealthoutcomes,
experienceofcare,andhealthequity,whilealsoensuringthemosteffectiveuseofhealthcare
resources.
Measuresofperformanceandimpactshouldbemeaningful,actionable,andtransparentto
consumers,patientsandfamilycaregivers.
Newpaymentmodelsshouldbeassessedusingmeasuresthataremeaningfultopatientsandfamilies.
Theyshouldprioritizetheuseofmeasuresderivedfrompatientgenerateddatathataddressbothcare
experienceandoutcomes.Measuresshouldalsoaddressthefullspectrumofcare,carecontinuityand
overallperformanceofspecificmodels.Measuresshouldbegranularenoughtoenablepatientstomake
informeddecisionsaboutprovidersandtreatments.
Primarycareservicesarefoundationalandmustbeeffectivelycoordinatedwithallotheraspectsof
care.
Paymentmodelsshouldfosterthiscoordination,particularlybetweenprimaryandspecialtycare,in
ordertopromote:optimalcoordination,communicationandcontinuityofcare;trustedrelationships
betweencliniciansandpatients/families;concordancewithpatientgoals,valuesandpreferences;
integrationofnonclinicalfactorsandcommunitysupports;andcoordinationofservicesdelivered
throughnontraditionalsettingsandmodalitiesthatmeetpatientneeds.Effectivedeliveryand
coordinationofprimarycareservicesshouldpromotebettercareexperience,optimalpatient
engagement,betterhealthoutcomes,andincreasedhealthequity.
Healthequityandcareforhighneedpopulationsmustbeimproved.
Newpaymentmodelsshouldfosterhealthequity,includingaccesstoinnovativeapproachestocareand
preventinganydiscriminationincare.Theyshouldcollectdatathatallowsforassessmentofdifferential
impactsandtheidentificationandredressofdisparitiesinhealth,healthoutcomes,careexperience,
access,andaffordability.
Patientandfamilyengagementandactivationshouldbesupportedbytechnology.
140
Newpaymentmodelsshouldpromoteuseofinformationtechnologythatenablespatientsandtheir
designatedcaregiverstoeasilyaccesstheirhealthinformationinameaningfulformatthatenablesthem
tousetheinformationtobettermanageandcoordinatetheircare.Thetechnologyshouldalsoenable
patientstocontributeinformationandcommunicatewiththeirproviders,anditshouldfosterpatient
clinicianpartnershipinongoingmonitoringandmanagementofhealthandcare.
Financialincentivesusedinallmodelsshouldbetransparentandpromotebetterqualityaswellas
lowercosts.
Financialincentivesforprovidersandpatientsshouldbefullydisclosedsothatpatientsandconsumers
understandhownewpaymentapproachesdifferfromtraditionalfeeforservicemodels,andhow
certainincentivesmayimpactthecareprovidersrecommendorprovide.Financialincentivesshouldbe
developedinpartnershipwithpatientsandconsumersinordertoreflecthowpatientsdefinevalue,and
toreducefinancialbarrierstoneededcareandensurethatpatientsarenotsteeredtolowercostcare
withoutregardforquality.
141
AppendixK:Resources
AgencyforHealthcareResearchandQuality.(2003).HCUPNet,HealthcareCost&UtilizationProject.
ComplicationsofPregnancy,Childbirth,andthePuerperium.Retrievedfrom
http://hcupnet.ahrq.gov/
AgencyforHealthcareResearchandQuality.(2011).HCUPFactsandFigures:StatisticsonHospital
basedCareintheUnitedStates,2009.Retrievedfromhttp://www.hcup
us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_report_2009.pdf
AgencyforHealthcareResearchandQuality.(2013).HCUPNet,HealthcareCost&UtilizationProject.
CertainConditionsOriginatinginthePerinatalPeriod.Retrievedfromhttp://hcupnet.ahrq.gov/.
AgencyforHealthcareResearchandQuality.(2016).CAHPSSurveysandGuidance.Retrievedfrom
http://www.ahrq.gov/cahps/SurveysGuidance/index.html
AHIPCoverage.(2016).AHIP,collaborativepartnersannouncecoresetofqualitymeasures[Press
release].Retrievedfromhttp://www.ahipcoverage.com/2016/02/16/ahipcollaborative
partnersannouncecoresetofqualitymeasures/
AmericanAcademyofPediatrics,Riley,L.,&Stark,A.R.(2013).Guidelinesforperinatalcare.American
AcademyofPediatrics.
AmericanCollegeofObstetriciansandGynecologists.(2014).Safepreventionoftheprimarycesarean
delivery.Retrievedfromhttps://www.acog.org//media/ObstetricCare
Consensus%20Series/oc001.pdf
Bell,S.K.,Mejilla,R.,Anselmo,M.,Darer,J.D.,Elmore,J.G.,Leveille,S.,...&Walker,J.(2016).When
doctorssharevisitnoteswithpatients:astudyofpatientanddoctorperceptionsof
documentationerrors,safetyopportunitiesandthepatientdoctorrelationship.BMJquality&
safety,bmjqs2015.
BlueCrossBlueShieldAssociation&BlueHealthIntelligence.(2015).Astudyofcostvariationsforknee
andhipreplacementsurgeriesintheU.S.Retrievedfrom
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