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Optimizing Reimbursements in Medicare's Value-Based Model

Monday, July 24, 2017   (0 Comments)
Posted by: John Richmond, Sequence Health
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It’s been more than a year since Medicare implemented its Medicare's Comprehensive Care for Joint Replacement Model (CJR) across 800 facilities in 67 test markets. It’s been a bumpy ride: Healthcare consultancy Avalere says that 60% of the hospitals impacted by CJR are incurring costs higher than regional and historic benchmarks. This is precisely why Medicare implemented its bundled payment model to discourage, and these providers could face financial difficulties if they fail to curb costs before reimbursements become directly tied to performance.

Consider this a wake-up call for the future of payer reimbursement. Regardless of what healthcare legislation lawmakers end up adopting, cost reduction is going to have a starring role and value-based reimbursement models can be expected to expand. Aetna, Blue Cross Blue Shield, and Cigna are also implementing their own bundled payment programs that use similar metrics to form the basis of reimbursement.

Many -- and quite possibly most, or all -- healthcare providers can expect to see significant changes to how both private and government payers reimburse them for services over the next several years. Providers that fail to meet new reimbursement requirements will risk financial solvency and long-term survival.

As the largest benefactors of CJR start to stratify from the practices that continue to struggle, key differentiators have emerged that you can use as best practices to ensure that you are ready for value-based reimbursement when it begins to impact your practice.


Coordinate care across multidisciplinary teams

One of the largest disruptors to the way bundled payments impact reimbursements is they pay hospitals and ancillary stakeholders like pre- and post-surgical care providers simultaneously. These reimbursements are based on patient outcomes, so each provider has a vested interest in coordinating care and working together to build synergies that help yield the best possible outcomes. At the same time, they remain independent entities that are focused on their individual aspects of care and sometimes do not have direct accountability to one another. The hospital has the role of overall care coordinator and is responsible for tracking the performance across care teams and patients on their journeys through the episode. Hospitals that understand this role and take active steps to ensure that care providers communicate with each other, track progress, and work toward the same goals are coming out ahead.


Actively manage patients on flexible care pathways

As patients move along evidence-based care pathways developed specifically for them, it is vital that provider performance is tracked closely along the way. Each stakeholder must have insight into the actions of others while maintaining autonomy to manage their own tasks, set reminders, and determine when patients need outreach or intervention. This dichotomy of coordination and autonomy is eased when every member of the team uses the same technology platform and has complete visibility into the actions and plans of every stakeholder. Shared platforms or automated sharing between platforms ensures aggregated insights and workflow efficiencies that improve adherence to evidence-based care plans with less chance for human error. Every patient is different and changes to care plans often become necessary along the journey -- each care member should have the ability to alter the care pathway in a way that is transparent to every other stakeholder so they can also adjust course accordingly. Ideal care pathways utilize existing IT infrastructure and update plans in real-time to reflect EMR changes that are easily visible to all providers on care teams.


Use patient-centric processes to achieve the best results

Concierge-style patient experiences provide better outcomes and improved satisfaction rates, and they rely on all caregivers sharing responsibility to deliver a streamlined experience. This process begins with pre-operative patient education and continues with engagement throughout the entire episode until a positive outcome is reached. Secure communication avenues between providers like enhanced email keeps everyone on the same page and over time, identifies meaningful trends in aggregated experiences that can be used to enhance future outcomes. However, it’s important to remember to keep e-mail HIPAA compliant and is recommended to be thoroughly vetted by IT and compliance departments before implemented. Patients whose care members regularly coordinate with each other and deliver an integrated experience report higher levels of satisfaction and perceived caregiver competency, and that psychological security plays a role in improving outcomes.


Reduce readmissions through patient engagement

Almost half of Medicare’s episode payments are related to post-discharge care. This is where the most impactful financial results can be achieved. Engaging patients starting with the onboarding process that assesses needs and risks and updating these factors through the process helps providers deliver the education patients need to help manage their own recoveries. Daily surveys are one way providers can engage patients in their own recoveries while uncovering updated risk levels to address patient issues before readmission becomes necessary. Intercepting complications early and reducing readmission rates achieves all the goals of CJR: it generates better outcomes, improves satisfaction rates, and lowers costs. Engagement and readmission are inversely related and leveraging that correlation is a powerful tool in achieving the best reimbursements in value-based models.

These reimbursement models reward coordinated team approaches to care. Medicare’s goal is to reduce payments while improving outcomes through motivating efficiencies in the process, and hospitals can achieve this by using technology to streamline communications and track performance across care teams while integrating with existing EMR platforms.


About the Author

John Richmond is the CEO at Sequence Health a cloud-based technology and services company that improves profitability and patient outcomes for hospitals and practices through end-to-end patient engagement solutions backed by clinical and non-clinical teams.

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