Writing for the Harvard Business Review, Derek Haas—CEO of Avant-garde Health—and Jamie Chang—CCO at CHA Hollywood Presbyterian Medical Center (HPMC)—outline the six steps HPMC took to succeed in CMS' Bundled Payments for Care Improvement Advanced (BPCIA) model.
HPMC's 6-step plan
1. Develop the right team and governance
Once it enrolled in BPCIA, HPMC developed a new continuing care team (CCT) dedicated to BPCIA, Haas and Chang write, which was tasked with identifying likely BPCIA patients and which would follow confirmed BPCIA patients from hospitalization through 90 days post-discharge. Among other post-discharge tasks, CCT worked with case management to determine the appropriate care levels for post-discharge BPCIA patients and provided access to a 24/7 nurse advice hotline to avoid unnecessary ED use.
To keep everything on track, a group of multidisciplinary stakeholders, including CCT, met each week and reviewed the list of patients at the hospital likely to be classified in the BPCIA program by Medicare, reviewing each patient's goals and—if appropriate—developing action plans for those in need of advance planning or inpatient hospice care.
Meanwhile, HPMC's management team met each month to review performance in the program, analyze the impact of improvement initiatives, and discuss any future opportunities to improve cost and post-discharge outcomes, Haas and Chang write, while the HPMC board of directors met quarterly to review finances and approve vendor contracts.
2. Leverage analytics
In 2018, to help prepare for BPCIA, HPMC partnered with Avant-garde Health to determine the care areas where it would adopt bundled payments. Once enrolled, HPMC was able to use Avant-garde's analytics to predict what the bundle cost for every patient would be and compare predicted patient costs to CMS' target prices.
Avant-garde also provided HPMC with analysis of post-acute provider performance used by BPCIA patients and benchmarked performance metrics against those of peer hospitals, helping to identify potential areas for improvement. In addition, the company helped HPMC engage its physicians with scorecards, quality metrics, and more for their patients in the program.
3. Emphasize managing post-acute care spending
When it enrolled in BPCIA, HPMC set up a post-discharge clinic on-campus for patients, only to learn that it didn't appeal to patients. As a result, HPMC shut down the clinic and instead transitioned to a home-based care model with a team of nurses and patient navigators, Haas and Chang write.
By providing home-based care, HPMC found that it was able to improve patients' medication compliance and increase the number of patients who reached out to their care team rather than going to an ED.
According to Hass and Chang, HPMC also contracted with a health information exchange company to notify HPMC when a BPCIA patient checked in for care at any hospital that worked with the organization, enabling HPMC to ensure the patient's care was coordinated care with the CCT team.
HPMC also regularly met with and collaborated with skilled nursing facilities to improve care.
4. Make end-of-life care better
HPMC began an inpatient hospice program and started proactively informing patients and families about the benefits of hospice care, Haas and Chang write.
The hospital found that offering discussions about advanced care-planning discussions helped ensure patients had access to end-of-life care options such as hospice care. HPMC was also able to educate physicians about end-of-life care.
5. Get physician buy-in
HPMC's medical staff is independent, meaning it was important to align the team's financial incentives with the BPCIA program, Haas and Chang write.
To do this, HPMC offered the medical staff gainsharing agreements in which physicians would share in the money earned by HPMC in BPCIA, but would not lose money if HPMC failed to meet CMS' spending targets—an incentive that, coupled with the actionable data provided via patient scorecards and quality metrics, "led many physicians to collaborate more fully with HPMC."
6. Make coding efficient
Before enrolling in BPCIA, HPMC's coding team reviewed documentation only after a patient was discharged—meaning the DRG, or the code used to establish whether a patient would qualify for BPCIA, might not be assigned until between one and two weeks post-discharge, Haas and Chang write.
Once HPMC enrolled in BPCIA, the hospital transitioned to reviewing documentation every day for every patient to ensure a patient's DRG was immediately identified, enabling HPMC to more efficiently identify likely BPCIA patients, engage with those patients early on in their stay, and help those patients identify the right kind of post-discharge care.
HPMC sees success with BPCIA
Since HPMC enrolled in BPCIA in 2018, it has seen success in three key areas, Haas and Chang write:
- Reduced readmissions;
- Reduced spending on both skilled nursing and inpatient rehab care; and
- Reduced physician billing.
Specifically, HPMC has seen medical care for patients cost 15% less than CMS' targets. HPMC has also seen 90-day post-discharge mortality rates for seven bundles it has participated in since launching its BPCIA efforts—including three cardiac and four medical and critical care bundles—drop by nine percentage points, while the 90-day readmission rates in those bundles dropped by five percentage points. And because of these early successes, HPMC has added two neurologic care bundles in 2020 before expanding to participate in all the bundles for which it is eligible in 2021.
"As HPMC shows, with engagement from all stakeholders—patients, physicians, hospital staff, and post-acute facilities—it is possible to drive meaningful improvements in care quality and costs in a relatively short amount of time," Haas and Chang write (Haas/Chang, Harvard Business Review, 3/30).