90 Days to Bundled Payments: Roadmap and Methodology for Implementing Your Bundled Payments Initiative

90 Days to
Bundled Payments
May 28, 2015

shamburger@thearistonegroup.com
(248) 613-7166
Sheldon Hamburger

Background
Today’s presentation
• Case study(ies)
• Lessons learned
• You’re the payer
• Executive leadership is essential
• Opportunity tends to be in post-acute
• Doing the right thing is most profitable

Bundled Programs
PAC
70%
DRG+Savings
30%PAYER

The Future
PAC
100%
New DRG
PAYER

Anchor Stay
44%
Ambulatory
4%
HHA
5%
Readmission
s
13%
IRF
9%
LTAC
4%
Other
2%
SNF
18%
Sample Hospital
Total Program 100% $113,000,000
Anchor Stay 44% $50,000,000
Post-Acute 56% $63,000,000
Ambulatory 4% $5,000,000
HHA 5% $6,000,000
Readmissions 13% $15,000,000
IRF 9% $10,000,000
LTAC 4% $5,000,000
Other 2% $2,000,000
SNF 18% $20,000,000

Agenda
0-30 30-60 60-90
Tactical Planning

Agenda
0-30 30-60 60-90
Tactical Planning
Organizational Alignment

Agenda
0-30 30-60 60-90
Tactical Planning
Convener Selection

Agenda
0-30 30-60 60-90
Tactical Planning
Convener Selection
Bundle Selection

Agenda
0-30 30-60 60-90
Tactical Planning
Convener Selection
Bundle Selection
(CMS) Contract Process

Agenda
0-30 30-60 60-90
Tactical Planning
Convener Selection
Bundle Selection
Post-Acute Care Design

Agenda
0-30 30-60 60-90
Tactical Planning
Convener Selection
Bundle Selection
Performance Metrics

Tactical Planning
Planning components
• Formalized plan
• Team approach
• Project management
• Managing competing priorities

Tactical Planning
Formalized plan
• Use of formal methodologies
• Use existing standards where available
• Sample tools such as:
– Project plan
– Regular status report
– Issue log
• Regular communication is essential
• Plan maintenance is a key success factor

Tactical Planning
Organizational structure
• Dedicated operational teams
• Multidisciplinary team:
– Clinical
– Legal
– IT
– Finance
• Requires oversight/governance

Governance Team
Chair:
Members:
Frequency:
Charter:
Care Coordination Team
Chair:
Members:
Frequency:
Charter:
Bundle Integration Team
Chair:
Members:
Frequency:
Charter:
Gainsharing Team
Chair:
Members:
Frequency:
Charter:
Team Definitions
GENERIC ROLES
COO - Chief Operating Officer for the program
CFO - Chief Financial Officer for the program
CMO - Chief Medical Officer for the program
CNO - Chief Nursing Officer for the program
CIO - Chief Information Officer for the program
CQO - Chief Quality Officer for the program
CCCO - Chief Care Coordination Officer for the program
CCO - Chief Compliance Officer for the program

Governance Team
Key Activities
• Program oversight
• Strategy and planning
• Decision making
• Direction
• Leadership
• Compliance
• Ultimate program responsibility
Note: Meet monthly - Communication critical

Care Coordination Team
Key Activities
• Care coordination metrics
• Staffing – Care Navigator
• Care transition policies & process
• Education – program rules & care transitions
• Risk stratification

Bundle Integration Team
Key Activities
• Bundle metrics
• Staffing
• Update/standardize care protocols/pathways
• Bundle-related documentation (patient/provider)
• Program education strategy
• Risk stratification

Gainsharing Team
Key Activities
• Define gainsharing terms
• Decision making / oversight
• Fund distribution
• Entity / Professional eligibility
Note: Ad-hoc meetings until distribution begins.
Quarterly thereafter.

Tactical planning
Project Management
• Importance of dedicated project manager (PM)
– Provide day to day leadership and focus
– Ensure progress toward success
• PM roles/responsibilities
– Maintains the structure and processes
– Tracks budgets and scope
– Coordinates resources
– Ensures that a quality program is delivered

Tactical Planning
Managing competing priorities
• “I already have a job”
• Support from highest levels of organization
• Shift priorities / delegate work
• Reliance on teams

Tactical Planning
How we did it
• Full team kickoff meeting
• Immediate team assignments
• Immediate team meetings
– Action driven
– Structured reporting
• Immediate work initiation
• External PM

Leadership from the top
• This is wholesale change to thinking
• Organizational commitment
– Across all departments/disciplines
• Culture shift
• Continuous focus on “getting it right”

Managing change
• Clear, consistent messaging
• Set realistic expectations / timelines
• Phased approach
• Identify problems early
• Enforcing accountability

Education
• Leadership
• Surgeons
• Clinical staff
• Case management/social work
• Post-acute provider providers
– Preferred and non-preferred
• Patient
Note: Start early and educate continuously

Systems/methods
• Leverage existing resources
– Video/intranet/classroom
• Marketing
– Copy and production
• Materials
– Presentations, white papers, news items
• Industry conferences
– Financial, clinical, topical

Leadership education
• Kickoff meeting
• Governance meeting
• Peer to peer
Surgeon education
• Surgeon champion(s)
• Part of leadership team
• Ad-hoc meetings with other surgeons
• Financial models

Clinical Education
• Service line managers
• Care coordination team managers
• Part of leadership team
• Train the trainer approach

Post-acute provider education
• Begins with network development
• Continues through selection/rejection
• Group and individual meetings
• Preferred and non-preferred providers

Patient education
• Consistent messaging from everyone
– Physicians
– Program sponsors and employers
• Emphasis on quality and care coordination
• Pre-admission through end of episode
• Collateral: handouts, wall-charts, multi-lingual

How we did it:
• Start early
• Leverage existing capabilities
• Re-purpose existing materials
• Include all levels of organization
• Sell the message

Convener Selection
The role of the convener
• BPCI specific role
• CMS general contractor
• Not required
• May/may not bear risk
• Generally bring a data partner
• Aggregate awardees (like you) to share lessons
• Source of information/strength vis-à-vis CMS
Convener

Convener Selection
Do I need a convener?
Yes No
Leverage their experience Have dedicated resources
“Ready-to-go” Contract with data partner
Shared lessons learned Experienced in value-based
Bring resources Save the money

Convener Selection
Changing your convener
• Allowable
• No time for selection process
• Big issue: delay in getting data
• Immediate issue: paperwork/processing time
• BPID, DUA, EFT

Convener Selection
How we did it
• Planning (including Plan B)
• Set expectations within the organization
• Push, push, push
• Constant attention to every step

Bundle Selection
Key drivers for your strategy
• Institution specific
– Your areas of specialization
• Geographic specific
– Patient demographics
• Payer specific
– What’s in/out?
– Pricing benchmarks

Bundle Selection
Key drivers for your strategy
• Availability of data
– Internal and payer systems
– Experiential
• It’s all about post-acute spend
• Ability to drive/driven positive change
• Volume creates leverage
• General spend trend line for the bundle
• Understanding of post-acute environment

Bundle Selection
Key data points for your selection
• Overall episode volume by DRG, surgeon, etc.
• Distribution of spend within an episode
– Average, over time, by setting, per episode
• Trend in quarterly average spend
• Readmissions: rates and reasons
• Episode duration (30, 60, 90)
• Risk track selection (BPCI)

Bundle Selection
Bundle #
Avg.
Spend
Anchor LTCH
IP
Rehab
SNF
Home
Health
Readmits OP Part B DME
Major Lower Joint 12 29.5K 40% 0% 0% 20% 8% 5% 9% 17% 0%
Bundle #
Avg.
Spend
Min Max Benchmark
Major Lower Joint 76 43.1K 16.6K 90.7K 45.9K

Bundle Selection
HHA 9%
Readmits Part B 17%
14%
150 Episodes $22.6K Avg. Spend
Anchor 27% SNF 26%
IRF 1% DME 2%
Congestive Heart Failure
Spending by site
OP 4%

Bundle Selection
Congestive Heart Failure
159
Episodes
21.6K
Average Cost
(18.3K-24.9K)

Bundle Selection
What if I don’t have my payer data?
• Internal and experiential data
– Volumes by DRG, surgeon, setting
– Readmissions
• Review process changes in past several years
– Readmissions
• Drivers of positive results that effect post-acute
– e.g., SNF referral, HHA affiliation/utilization

Key CMS contract documents
• Awardee Agreement
• Attachment B – Implementation protocol
• Attachment C – Awardee profile
• Attachment F – Gainshare List
• Attachment G – Secondary Repayment Sources
• Skilled Nursing Facility (SNF) List

Approach to the contract process
• Divide and conquer
• Legal, finance, clinical roles
• Regular, ongoing focused meeting/sessions
• Driven/coordinated by project manager
• Accountability to peers and Governance

Contract Component Responsible Team Key Issue
Awardee Agreement Legal "as is"
Implementation protocol
Care Coordination, Bundle
Integration, Finance, Legal
intense drill down
Awardee profile Finance risk analysis
Gainshare List Operations/Legal contracting issues
Secondary Repayment Sources
(SRS)
Finance paperwork
Skilled Nursing Facility (SNF) List
Care Coordination & Bundle
Integration
risk analysis

Implementation protocol
• Program governance/structure
• Care redesign process
• Gainsharing/financial arrangements

Program governance/structure
• Started with template
• Team review/edits
• Oversight, gainsharing, quality issues
• Final internal consensus

Care redesign process
• Required regardless of contract !!!
• CMS defined categories
• Analyze current/future states
• Deliver final consensus and plan

Gainsharing arrangements
• Money drives behavioral change
• Who drives change? Surgeons!
• Payments must be quality based
• Negotiate quality measures/results
• Agree on financial splits

How we did it
• Start early
• Use of templates
• Assign work to teams (internal clinical resources)
• Develop sense of urgency
• Ongoing forward progress driven by deadlines
• Management negotiation with gainsharers
• Constant review and refinement

Bundles are about post-acute spend
• This is the source of your profit
• Efforts should be focused here
• Strategy is in optimizing that spend
– Direct post-acute care utilization
– Readmissions

Anchor Stay
44%
Ambulatory
4%
HHA
5%
Readmission
s
13%
IRF
9%
LTAC
4%
Other
2%
SNF
18%
Total Program 100% $113,000,000
Anchor Stay 44% $50,000,000
Post-Acute 56% $63,000,000
Ambulatory 4% $5,000,000
HHA 5% $6,000,000
Readmissions 13% $15,000,000
IRF 9% $10,000,000
LTAC 4% $5,000,000
Other 2% $2,000,000
SNF 18% $20,000,000

Key post-acute partners
• SNF, HHA, IRF
• Your own ER (and other ERs)
• Community resources
• Partner’s effect is bundle specific
• Optimizing utilization is the goal

SNF # Episodes
Total
Payment
Average
Payment
Readmissions
Readmission
Rate
SNF 1 80 $785,461 $9,818 6 8%
SNF 2 25 $301,225 $12,049 4 16%
SNF 3 25 $187,522 $7,501 1 4%
SNF 4 23 $354,001 $15,391 0 0%
SNF 5 17 $196,222 $11,542 4 24%
SNF 6 12 $164,526 $13,711 3 25%
SNF 7 11 $255,124 $23,193 2 18%
SNF 8 11 $91,230 $8,294 1 9%
SNF 9 10 $115,235 $11,524 3 30%
SNF 10 8 $152,134 $19,017 0 0%
SNF 11 7 $48,256 $6,894 2 29%
SNF 12 6 $44,120 $7,353 1 17%
SNF 13 4 $56,125 $14,031 0 0%
SNF 14 3 $14,597 $4,866 1 33%
SNF 15 4 $39,256 $9,814 0 0%
SNF 16 3 $13,021 $4,340 1 33%

HHA # Episodes
Total
Payment
Average
Payment
Readmissions
Readmission
Rate
Our own HHA 132 $422,123 $3,198 12 9%
Competitor 22 $93,213 $4,237 4 18%
Competitor 15 $87,456 $5,830 3 20%
Competitor 12 $48,213 $4,018 3 25%
Competitor 10 $35,124 $3,512 1 10%
Competitor 9 $15,784 $1,754 2 22%
Competitor 8 $23,549 $2,944 0 0%
Competitor 7 $22,056 $3,151 5 71%
Competitor 7 $18,452 $2,636 2 29%
Competitor 7 $18,547 $2,650 0 0%
Competitor 6 $18,213 $3,036 1 17%
Competitor 6 $24,153 $4,026 1 17%
Competitor 5 $17,918 $3,584 0 0%
Competitor 4 $72,123 $18,031 1 25%

Why a post-acute network?
• Ensures best quality/performance
• Creates standardized/compliant care
• Develops competition toward improvement
How to create the network?
• Formal selection process
• Internal input to performance metrics
• Open to everyone

Challenges
• Timeframe
• Internal pushback
• External pushback
Sample performance criteria
• Reduction in LOS
• Reduction in readmissions
• Adherence to our protocols/pathways

Key Activities
• RFP process
– Open to all
– Time for questions/feedback
– Scoring/evaluation process
• Partner integration
– Develop initial integration strategy/plan
– Develop integration process

How we did it
• Start with templates
• Communication from C-suite about the process
• Adherence to timeframe
• Partner integration

Performance Metrics
Defining metrics from the start
• Can’t improve what you can’t measure
• Measure twice, cut once
• Must align with project goals
• Don’t do too much at once/from the outset
• “Dashboard” comes later

Performance Metrics
Where to begin
• Categories: financial, clinical, patient satisfaction
• What do you have today?
• Pick a limited set of new key drivers
• Questions to ask:
– Do we have it today? Where do we get it?
– Priority for launch? Who is the user?
– How often would the user need to see updates?
– How is it deployed to the user?

Performance Metrics
Data Capture
• Fit in existing workflow/system
• Must measure what you want
• Requires cross functional teams
Data integration
• Key identifiers (unique)
• Disparate systems

Performance Metrics
PROJECTED TARGET PRICE VS. PROJECTED SPEND = "P&L"
Facility DRG
Projected
Target
Projected
Spend
Delta
#
cases
Ext. Delta
LOC 1 DRG 1 $49,500 $55,000 ($5,500) 7 ($38,500)
LOC 1 DRG 2 $26,000 $25,800 $200 255 $51,000
LOC 2 DRG 1 $48,500 $52,000 ($3,500) 4 ($14,000)
LOC 2 DRG 2 $26,000 $23,500 $2,500 91 $227,500
357 $226,000
Bundled spend = DRG basis + post-acute proxies
SNF days x $500
HHA days x $150

Performance Metrics
Measure Description Numerator Denominator
Sources of
Data
Measure
Period
Comparison
Standard
Readmission
rate (MLJ)
Overall 30 day
readmission rate
for MLJ patients
All readmissions
to inpatient status
within 30 days of
All MLJ patients EMR Quarterly <= 5.4%
DVT/PE rate
DVT/PE rate for
MLJ patients
All MLJ patients
with lower
extremity DVT
ICD 9 code during
hospitalization
All MLJ patients QC system Quarterly <= 1.2%
Have these Negotiate
these
Gainsharing

Performance Metrics
In total, by SNF, by bundle
SNF Performance Scorecard
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
# Referrals 10 12 13 8 15 11 4 7 12 12 7 9
Referral rate 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10%
Avg. LOS 9.2 8.1 11.2 15.1 10.1 11 10.4 11.2 14.1 9.4 9.2 10.1
Readmission rate 30% 33% 46% 25% 7% 45% 25% 29% 8% 42% 29% 56%

Performance Metrics
Process Metrics
Hospital Quality
Measure
Hospital Performance
Measure
Program Goal
Measurement
Standard
Current
Measure
Where was Measure
Published
Association
that
compiled the
measure
How to Measure
(Numerator/
Denominator)
Medication
Management
Percentage of patients in
the hospital that had a an
assessment of medication
intake, patient and family
were counseled about their
medication, and medication
management was a part of
the patients plan of care
Improved transitions
of care and
reduction in hospital
readmissions
80%
National Transitions
of Care Collaborative-
Category 1 of 7
essential Intervention
Categories
Transition Planning
Percentage of patients in
the hospital setting that
used a formal transition
planning tool such as a
standard Transition Form
(AMDA Universal Transfer
Form) or Patient Plan of
Care tool developed in the
hospital and extended to
the SNF facility
Improved transitions
of care and
reduction in hospital
readmissions
85%
National Transitions
of Care Collaborative-
Category 2 of 7
essential Intervention
Categories

Performance Metrics
How we did it
• Start with existing reports
• Identified several key metrics per area
– “P&L”
– Bundle performance (data vendor)
– Post-acute metrics (e.g., discharge patterns to SNF)
• Manual tracking (some automation)
• Increase automation over time

Questions ?
Sheldon Hamburger
Principal
shamburger@thearistonegroup.com
(248) 613-7166

90 Days to Bundled Payments: Roadmap and Methodology for Implementing Your Bundled Payments Initiative

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