Bundled Payments

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Product Overview

The Bundled Payments application evaluates cost and variation associated with care delivery for patients and is intended to prioritize areas of focus and provide a baseline for exploratory analysis. The application is modeled on Centers for Medicare and Medicaid Services (CMS) bundle definitions. In addition, the application supports custom bundle development.
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Features

  • Bundle risk: Gives you an understanding of revenue-at-risk compared to CMS-mandated reimbursement models. Regional performance benchmarks are calculated using the Medicare Standard Analytical File.
  • Opportunity analysis: Evaluate variation in cost and revenue-at-risk to identify the bundles with the biggest opportunities for improvement.
  • Self-service analytics: Find root cause of bundle variation. Look across specific locations, settings, providers, and utilization trends to find actionable insights.
  • Claim File Augmentation: Augment gaps in your claims database using the Medicare Standard Analytical File.

Benefits

Benefits Include:

  • Gain insight into your at-risk CMS revenue based on target benchmarks calculated using your historical performance and your region's performance; provide tools to proactively manage and track that risk
  • Identify variation for episodes of care to find opportunities to improve care coordination across your health system
  • Identify opportunities to provide competitively priced bundles and drive volume to high-performing bundles

Measures

Available Measures include:

  • System bundle performance compared to regional benchmarks
  • Variation in total payment, by bundle
  • Average/total spend per episode by location, care setting, and provider
  • Readmission per episode by location, care setting, and provider

See Sample Screenshots of Bundled Payments

Data Sources

  • These data sources are required for full functionality to look at both in- and out-of-network care: Paid claims for inpatients and outpatients plus associated membership and provider files.
  • Securing a secondary data use agreement is required to see regional performance benchmarks from the Medicare Standard Analytical File.

Bundled Payments: A Deeper View

Background

Bundled payment initiatives attempt to reduce care fragmentation and improve overall quality of care by aligning incentives between all providers—including hospitals, physicians, and post-acute care providers—that touch a single episode of care. Instead of issuing separate payments to each of the participating providers, the payer issues a single payment for the episode of care. Participating providers need to work closely with any provider that provides services to the patient as a part of that episode to manage costs and overall quality. CMS is currently piloting a bundled payment program, called the Bundled Payment for Care Improvement Initiative (BPCI).

What types of problems does Bundled Payments address?

To secure incentive dollars for participating in the bundled payment program, participants must work to control costs and manage quality with all providers that participate in the patient’s episode of care. Understanding sources of cost and variation in cost across settings and the providers that participate in the episode is critical.

Users

  • Service-line leaders: focus on bundle performance risk profile and opportunity analysis
  • Clinical analysts: focus on root cause analysis

Use Cases

  • A health system leadership team wants to prepare for the upcoming requirements for the CMS bundles initiative, as well as determine opportunities within various bundles across the healthcare system. They determine the top five needs in their system in collaboration with the clinical programs and incorporate those into the Bundled Payments application. They identify variation in cost across post-acute care settings and work with analysts to identify the root cause of the variation.
  • Using the Bundled Payments application, analysts determine that 90-day cost is lower in CJR patients who are discharged to SNF facilities than other care facilities. Armed with this information, the leaders launch an improvement initiative to increase discharges to SNFs post CJR inpatient events and track ongoing trends using the application.
  • The Millrock market has been selected by CMS to participate in the CABG and AMI mandatory bundles that start October 1, 2017. Millrock Health will be at risk for up to 90 days post discharge for selected qualifying encounters. Using the Bundled Payments application, Millrock leadership calculates target price based on historical and regional experience to understand their risk profile in this new payment model. They learn that they will need to reduce cost in delivering the CABG bundle by 4% to avoid reduction in reimbursement.

Anticipated Improvements

  • Gain insight into your at-risk CMS revenue based on target benchmarks calculated using your historical performance and your region’s performance; provide tools to proactively manage and track that risk
  • Identify variation for episodes of care to find opportunities to improve care coordination across your health system
  • Identify opportunities to provide competitively priced bundles and drive volume to high-performing bundles

Success Measure Examples

Opportunity Identification:

  • Identify potential money saved from reductions in variation on select bundles
  • Identify bundles to go at-risk for by evaluating cost and variation in each of the CMS-defined or custom episodes of care
  • Reduce costs in a selected bundle