Transcript TITLE OF PRESENTATION - South Carolina Hospital Association

Bundled Payments: An Initiative of
Payment Reform
Providence Hospital
BlueCross BlueShield of South Carolina
October 9, 2012
Current Trends for Payment Reform
Fee-For-Value
Collaboration
• Moving away from
rewarding for
activity and
toward paying for
outcomes
• Greater alignment
between payers,
providers,
employers and
patients to
improve quality,
efficiency and
outcomes.
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Business
Intelligence
• Utilizing data to
reduce the
enormous
variability in care –
not just reducing
cost
The Institute for Healthcare
Improvement’s TripleAim
A framework developed by
The IHI that describes an
approach to optimizing
health system performance.
Patient
Experience
• Improving the patient
experience of care (including
quality and satisfaction)
• Improving the health of the
populations
• Reducing the per capita cost
of health care
Population
Health
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Per Capita
Cost
Current Payment Innovations
Quality Based
Incentive Programs
•Rewards providers for achieving improvements in process,
efficiency, outcomes, infrastructure and patient safety
Patient Centered
Medical Homes
•Primary care physician coordinates a team that takes
collective responsibility for patient care and, when
appropriate, arranges for care with other qualified physicians
Accountable Care
Models
•Coordinated care that meets performance benchmarks for
member populations
Bundled Payments
•Pays providers with a single negotiated payment for all
clinically related services of the specific episode delivered by
various providers over a period of time.
Bundled Payments
 Utilize the PROMETHEUS Payment® (www.hci3.org)
 Designed by American College of Physicians, the Leapfrog
Group, the National Business Group on Health, the BlueCross
and BlueShield Association and CMS
 Claims are analyzed to determine a patient's conditions
and risk factors.
 Two types of claims: typical claims and claims associated with
Potentially Avoidable Complications (PACs).
 As PACs are reduced or eliminated, the leftover allowance
is distributed amongst all providers for the patient as a
bonus.
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Operational Model
 Retrospective Model
 Patients are identified through current authorization
process and a custom budget is created
 Severity-risk adjusted
 Claims are paid based on existing reimbursement
methodology as services occur (FS, DRG, etc.)
 After claims are paid during the pre-established time
frame, compare actual dollars paid to predetermined
budgeted amount.
 Quality measures are incorporated
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Benefits to Bundled Payments
“Spillover” effects
Opportunity to
strengthen
hospital-physician
alignment
•Changing practice
patterns for bundled
payment contracts and
extending these
practices and
producing similar
results—lower costs
and better quality—for
other patients
Allow hospitals
and physicians to
capture the value
created by process
improvement
efforts
Enhanced
revenues through
strategic
marketing efforts
Progress Towards Bundled Payments
Providence and
BlueCross started
discussions in
March 2011
Determined
quality indicators
and claim
operations
Determined how
patients were
identified
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Planning first
bundled payment
arrangement in
South Carolina
Questions
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