Even as the U.S. healthcare system moves forward in its transition from being a volume-based reimbursement system to being a value-based one, patient care organizations’ levels of readiness to adapt to payment change continue to vary considerably. That includes hospital organizations’ preparedness to participate in the comprehensive joint replacement (CJR) bundled payment program under the Medicare program. That CJR bundle had been made mandatory for hospitals and for affected physicians until November 30, 2017, when senior officials at the Centers for Medicare and Medicaid Services (CMS) announced that they were reducing the number of geographic markets mandated to participate in the CJR bundle from 67 areas to 34 areas.
Still, regardless of the specific parameters of the CJR program going forward, some hospital organization leaders are skating to where the proverbial puck is headed—in other words, moving forward to master CJR bundled payments—operationally, clinically, and financially. Leaders at the Altamonte Springs, Fla.-based Adventist Health System are among the teams doing just that. Indeed, with 16 hospital facilities from their 45-hospital integrated system already involved in the comprehensive joint replacement bundled payment program, Adventist Health System leaders made the decision a couple of years ago to pursue a bundled-payment performance improvement initiative, as a natural “next step” in their organization’s development.
And that initiative has borne abundant fruit.
Combining intensive process improvement efforts with the leveraging of data, Adventist Health leaders have made dramatic gains in performance: when comparing the organization’s first six months of CJR performance Year 2 to Performance Year 1 data, the health system has seen a 19-percent decrease in 90-day readmissions, a 17-percent decrease in discharges to skilled nursing facilities, and, depending upon the diagnosis-related group (DRG), a 3- to 17-percent decrease in acute hospital length of stay, among its 16 hospitals participating in the program. AHS has received in excess of $500,000 in reconciliation payments from CMS, for its performance. And all of these improvements were made possible through the strategic leveraging of data and analytics to support continuous performance improvement, including via the use of two performance improvement dashboards—one supplied by the Charlotte-based Premier Inc., and the other, a self-developed internal dashboard that provides near-real-time data for decision-making.
Because of their pioneering work, the editors of Healthcare Informatics have chosen the leaders of Adventist Health’s bundled-payment initiative as the number-two-winning team in the Healthcare Informatics Innovator Awards Program, Providers Division.
Speaking of the origins of their initiative, Stephen A. Knych, M.D., the vice president and chief quality officer at Adventist Health, says that “Our exposure to this process around bundled payments, which began a couple of years now, came out of the mandatory CJR bundled payment program out of CMS. So that was the genesis of this; we have a number of hospitals involved in this, so the impetus to get involved in looking at care through the bundles really came to us through that. The innovation required, and the comprehensiveness, was that the program required us to look at care according to episodes defined by CMS, extending out through 90 days post-discharge, for an elective hip or knee joint replacement, with or without fracture.”
That challenge, Knych says, “was a new experience for us and for healthcare in general, when you have to bring together the resources who take care of patients across this continuum, all in one room, and literally bring together the plans of those different and disparate functions, from how you optimize the patient’s ability to be successful before and after the surgery, to how you prepare them for the surgery, do the surgery, and take care of them 90-days-post, where you’re responsible for their care,” Knych says.
What’s more, Knych adds, “The second element of challenges facing the Adventist Health organization around CMS’s mandated bundled payment program “was how this model is structured—a five-year plan. Initially, most of the target prices, what you’re allowed to spend on these people for these episodes by CMS, were primarily weighted towards local people; but then, over time, towards MSAs [metropolitan statistical areas], which cover very large regions—the six MSA regions applicable to us go all the way up to Delaware on the East Coast. That’s a very large and diverse territory. So now you have a cohort of people from across huge regions like those, that your care processes have to align with,” [with] outcomes spanning very diverse populations across that region.
Speaking of the opportunity and challenge embedded in the mandatory CJR bundled payment program, Patricia (Patty) Fennell, R.N., director of clinical quality improvement at Adventist Health, says, “The mandatory CJR bundle was new to Adventist, as we hadn’t participated in any of the voluntary bundles. So, pulling together a multidisciplinary team, in order to bring together all the different disciplines” in order to master the processes, “was a blessing for us.” As a practical matter, that meant establishing a set of four different workgroups—one each for acute care, covering everything from performance in the preoperative phase, across the care continuum to discharge to non-acute care; a post-acute care workgroup; a workgroup that developed gainsharing incentives for physicians and included legal and other experts; and a fourth group dedicated to data and analytics. Those four workgroups—composed of 15 to 20 individuals in each group—went to work across the 16 hospital facilities operating within 11 clinically integrated networks within the Adventist Health system, beginning at the start of 2016. “We pulled a lot of people together, and the result was an eye-opener for us, and very helpful,” she adds.
Speed of Execution a Critical Success Factor
It’s important to keep in mind how quickly the workgroups had to make progress, Knych points out. “The performance period for those episodes for year 1 began April 1, 2016, so that essentially gave us roughly 90 days to get our act together, while the clock was ticking,” he emphasizes. “So as Patty said, the ability to bring everyone in was really critical to the speed with which this had to happen. And you’re looking at four states and six MSAs for our organization, so we had to make sure that that was adequately planned for, and those people were appropriately represented. We weren’t in any voluntary payment models, so this type of work was relatively new to us. And we became members of the bundled payment collaborative at Premier, so I want to give them proper credit, too.”
Another key element, Fennell says, has been the collaboration and information sharing across the organization, in order to improve performance. “We have the four workgroups, we have a steering committee, and we also do a call once a month with all of our sites, and we share tests of change, tools, and get information back from them on what’s working and not working. So we’re working collaboratively at the corporate headquarters, but also among all of our sites, so that’s been a kind of 'aha' moment for us,” she says.
Among the inevitable challenges: delays in obtaining claims data from CMS, and then the messiness of that claims data when it has arrived, and then the need to marry delayed CMS claims data with clinical data from within Adventist Health’s electronic health record (EHR). What’s more, Knych says, “These bundled payment programs demand that you travel with the patient from before they get their care all the way through 90 days after. What we encountered initially was that we didn’t have an already built mechanism where we could walk with them through their care process, to allow our hospitals to understand in real time how we were doing. So we had to develop a forward-facing, concurrent-care process, that could follow these patients all along, and could engage them all along, which we weren’t set up technologically to do.”
Dashboards Provide Intense Focus, Illumination
The leaders at Adventist Health have been extremely pleased with the Bundled Payment Intelligence Platform (BPIP) dashboard that they’ve installed, as provided by Premier Inc., through their participation in Premier’s bundled payments collaborative. At the same time, they realized that they needed to build and implement their own concurrent performance dashboard, as the BPIP dashboard provided only retrospective data and didn’t encompass such elements as quality outcomes measures or predictive analytics around cost. So, they built their own concurrent dashboard. “We had three or four months to prepare, and started with the basics, such as what was our volume for 460 and 470 patients?” says Ankush Bhagat, director of business analytics and data mining, for the health system, referencing the CJR codes. The end result of a number of months of work is that “We’re no longer reacting to bundles, he says. This has helped us to start planning better for new bundles; in fact, we’re already starting to look at new bundles that might come into place.”
The internal dashboard provides near real-time information on the beneficiaries (e.g. patients) with respect to length of stay, readmissions, ED visits, observation visits, and discharge dispositions, to name a few. The data is then analyzed for areas of improvement. Meetings are held with interdisciplinary teams at the hospitals both individually and as a group to discuss findings and to share best practices and lessons learned.
“And one key to our success has been that we’ve had involvement from all of our sites, not just headquarters,” says Jennifer Waterbury, senior bundled payment engineer. Adds Rhonda Lovec-Theobald, R.N., senior manager, clinical performance knowledge, “It was very key to bringing in analytics, so our clinicians understand the criteria and principles behind CJR. That improves the data quality of what we have.”
As for the change in physician culture that needed to take place for ultimate success, Knych emphasizes that “Physicians feel like they’re under attack these days from multiple different angles; they feel like they’re being told to change how they practice. But if you involve physicians very early, so that they can contribute to the process, and allow them the visibility to see how other physicians are practicing, in a safe, protected environment, if you enhance their capability to make decisions, and don’t attempt to take the decision-making away from them, they’ll usually make good decisions.