Episode 60: A Symposium Sneak Peek

Heather: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Heather Ward.

Mike: And I'm Mike Clark. Heather and I are practicing physicians and participants in the MaineHealth ACO. This month, we're talking to two folks who will be hosting one of the workshops at the MaineHealth ACOs Symposium on Value-Based Care, which is coming up later this month.

Heather: Yes. Jay Powers and Sue Seekins join us momentarily to give us a sneak peek at their workshop on bundled payments. Let's get to it.

Mike: So, Heather, later this month, participants in the ACO will be gathering in Freeport for a day of exploring value-based care. There will be an amazing keynote Dr. Don Berwick, yes Doctor Berwick and workshops, some fabulous workshops on ways to realize the promise of value-based care.

Heather: One crucial way to do that is involving specialists. In the past, our focus has really been on primary care and primary care value-based care efforts, but I think we are realizing that it's probably not sufficient for a full-on shift to the model. So, specialists are the key.

Mike: So joining us now are Dr. Jay Powers and Sue Seekins from MaineHealth. They're collaborating on a workshop to explore one way to engage specialists in value-based care. And that's using bundled payments. Jay and Sue spoke to our producer, Paul Santomenna.

Paul: Sue Seekins and Jay Powers, thanks for joining us. Could you first just introduce yourself? Sue, do you want to go first and tell us who you are?

Sue: Yes. Thank you for having us today. I am a program manager with the Cardiovascular Service Line for Maine Medical Center and MaineHealth. I've been working with the ACO on some of these advancing payment models and bundle payments in particular.

Paul: Thank you, Sue and Dr. Powers.

Jay: Hi, I'm Jay Powers. I'm a clinical cardiologist at Maine Medical Center. I've practiced here at Maine Med for 27 years. I am currently the division Director of Cardiology and the Director of Quality, Safety and Advanced payment models for the CV service line.

Paul: Great. Thank you. So diving in here. The ACO on May 22nd is having a value-based care symposium. And you're both leading a workshop on one component of that which are bundles known as bundles. So just for the uninitiated here, can you give us a rough idea of what payment bundles are and why they're of interest?

Jay: Yeah, I guess I'll start with the second question: why they're of interest. Over the last ten years, as CMS appropriately has moved towards value-based payments, there have been attempts at engaging specialists that have not been overly successful. And for some of those reasons are around relevancy. I guess you could say the actual impact to a physician's day to day practice and how these models might play a role really hasn't come to the surface and been important enough for them. So with some of the work that Sue and I have done in the past on behalf of the Maine Heart Center, which is now been sunsetted, we had an entity that since 1995 did bundle payment structures with private payers around multiple diagnoses, both in the cardiology specialty as well as vascular surgery. We come from a background of experience with 30-day bundles in the private pay models.

Jay: Sue and I became interested in this in the first iteration when CMS put out Bundle Payment Care initiative, the initial program back ten plus years ago, and the Heart Center was involved in that from this, specifically with the CT surgery bundle. And we went into this with one major priority that it was would be a learning experience, and that it was that kind of parlayed into our interest in their second iteration of the BPCI, which is called the Bundle Payment Care Initiative, Advanced BPCI-A. In that program, we were involved in two different bundles, specifically one procedurally based, and one medically based, namely outpatient catheter intervention and the inpatient chronic diagnosis of atrial fibrillation. That's kind of our background. And really all along our goal has been to gain engagement from our specialty partners. As we go forward, that goal is expanded not only in the cardiovascular sphere, but with some other colleagues. We're fortunate that we have Adam Rainer from orthopedics joining us, and he's going to share his experience at the symposium as the orthopedics world. We're looking forward to that.

Paul: Yeah. Great. Sue, do you want to talk a little bit about trying to define what bundles are?

Sue: Sure, I'm happy to do that. So you asked what payment models are. And basically really payment models are developed to test a different payment approach or an alternative way of paying for health care other than traditional fee for service. And so with bundle payments, a single overall price for a clinical episode of care, which usually lasts 30 to 90 days is assigned to the providers. And in that way, the providers are responsible for coordinating all the care that patients receive during the clinical episode, and that can include and is usually anchored by an inpatient hospitalization or an outpatient procedure, and then includes all the associated provider services once the patient is discharged: post discharge services for outpatient follow up, things like post-acute care services like skilled nursing facility care or home health services, as well as any emergency department visits or any unplanned readmissions. So essentially, all the care of the patient that the patient receives during the clinical episode is bundled into one price.

Paul: Okay, so to maybe oversimplify, you get paid a set rate to take care of a patient for a single episode, which centers around probably a surgery or something like that, and their recovery. My assumption is this puts you at risk for their outcomes, right? That obviously is if the outcome is poor, they're going to cost more money, and that essentially comes out of your pocket or the or the provider's pocket as opposed to the payer. Am I roughly on the right track?

Jay: Yeah, I guess I would say, first of all, this does include what we call medically based bundles. Things like heart failure and admissions for atrial fibrillation. So, it's not strictly procedurally based. And you're right, these bundles are risk adjusted, as Sue pointed out and based on the set amount, and it's actually customized. We, Sue and I, both agree that CMS did a really good job with the risk adjustment, and it was fair and transparent as to how they came up with that and how you can work within the parameters of that system, at least in BPCIA. So the bundle payment is set right up front, and then the providers are at risk, if you will, to stay within the limits of that bundle. If you exceed it, then, you know, there's obviously no shared savings. If you come in underneath it, then there would be shared savings for the providers.

Paul: Does everything get end up getting paid for even if you go over the set price?

Jay: Yeah.

Paul: But you just don't get in, there's no upside basically.

Jay: Right. Yeah. Nothing changes at ground level if you will. It's still fee for service. And then it's all kind of figured out retrospectively as to whether you stayed within the bundle or not.

Paul: Okay. You mentioned a couple different bundle types here, I think quickly, but can you give us a case study or zoom in on just one of these and give us the details of how a bundle works in practice?

Jay: Yeah, I think I'm going to Sue has a nice example prepared for us. I think I'll defer to Sue.

Sue: Episode based payment models. Excuse me. And bundles have actually been around for quite a while. Um, with hospitals moving to DRG reimbursement in the 80s, all hospital care is now bundled into one price. And then other payment model testing in the early 90s and 2000s demonstrated some cost savings for cardiac and orthopedic acute care episodes when they combined the hospital and physician and outpatient care into one bundle price. As Jay mentioned earlier, the Cardiovascular Specialists Network, administered a 30-day cardiac procedural bundle payment with commercial payers for many years, beginning in the mid 90s, and that offered access for diagnostic cardiac services at one of the outlying MaineHealth hospitals and allowed for a seamless transfer to Maine Medical Center if urgent or advanced treatment or surgery was needed. And then these contracts also included a 30-day no readmission guarantee for the payers.

Paul: Okay. From your experience with that bundle and others, what elements need to be in place to really succeed in these types of arrangements?

Jay: Just taking off on the last question too, specifically, as I mentioned, up top, we were most recently, we were involved in the BPCI-A around outpatient catheterization and atrial fibrillation. So as far as a case study, we can give you sort of an overriding case study. Interestingly, we went into that experience again with our primary goal is to learn the system, learn how to navigate the system and what tools are required, which I'll get to in just a second here. But interestingly, you know, we chose a procedurally based bundle with the cath and then the medically based with the AFib thinking that we would be very efficient with the procedurally based and we might take our lumps, the AFib. And in fact, it turned out to be just the opposite, which is was always fun. We learned from both of them, but we actually performed a lot better in the AFib bundle, which is a more longitudinal chronic care kind of type model. So that was great. What we did understand some of the most important elements were physician coding. I know that MaineHealth has done a lot of work on this over the last five years, and we worked closely actually at the time with Brett Loffredo on this and, you know, had multiple meetings and presentations to our providers to make the point how, you know, important it was for them to code the MCCs and the CCs when they were caring for patients.

Jay: And we did really see an improvement in that. And I think that that was part of why we were successful financially in the bundles overall. But some of the, you know, the background, more higher-level keys for success really came with buy in from MaineHealth and the institution for some financial risk. That's really, I think the writings on the wall. And maybe I'll get into this a little bit more later in the interview. But certainly, CMS is is committed to, you know, having 100% of their patients in value-based models by 2030. And this is a step along the way to engage and hopefully be successful in getting specialists involved.

Jay: Some of the other key points that we found to be really important was collaboration, obviously with primary care, collaboration with our SNF network and our discharge planners, as well as outpatient offices for providing timely follow up for patients, whether it be by telephone, in person or both, so that we were confident that we were providing, you know, high quality care to this population. I'm going to ask Sue to add a few more of our learning points.

Sue: I think one of the biggest opportunities and participating in programs like this is the amount of data that's available via claims. You have available large subsets of claims data, be it inpatient claims, outpatient claims, skilled nursing facility. Those are all sent to you as part of this program. So being able to accept that data and program it and make meaningful summaries to provide to the folks that are participating in these bundles is key. And it can't really be underestimated, to have that data available to utilize. It helps to look at identify gaps in care and any variations in care that you can sort of look at and design your quality improvement efforts around. It's also helpful to have clinical champions in the services that you're providing the bundle for, partnered with administrative leaders. Things like standardized clinical pathways are very helpful in improving quality and outcome. And as Jay mentioned, making sure you have complete coding capture of patient risk.

Paul: To sum up, if I can, again oversimplify because that's what I do. It's really about data and it's about buy-in. That might be the two big takeaways. Is that accurate?

Sue: And partnerships.

Jay: I was going to say education. I use the example around coding for MCCs and things, but just general education to that these models are out there, and this is the right way that we should be caring for patients. In my mind, that we're responsible to the health care payment systems and providing high quality care at an appropriate price. I think the education part is key.

Jay: I was just going to emphasize Sue's point around data analytics. In the past, we've had different experiences with either outside data analytic firms and certainly, you know, we're evolving at MaineHealth to having kind of the horsepower to do the analytics in-house, if you will. But that was really key for us. If you take for an example the BCI-A experience, we had to have the data. But the data analyzed was just really powerful for us to really follow folks week to week. In Sue's case, she would be following them almost day to day. But that that's really essential is, is to have real time data that comes in an understandable way for the team to take action on it.

Paul: Yeah. Thanks for clarifying that. Data is not enough. It has to be actionable and understandable.

Jay: Yes. Yeah.

Paul: I want to go up a level here for a second and talk about the problem of, if I can put it that way, the problem of specialists and value-based care. There's been a big focus in the early days of value-based care around primary care, and that's where sort of the leverage seemed to be. And a lot of measures were around primary care, care quality. So, bringing specialists in and making the case, and just talk to us a little bit about that, I mean, that's sort of the space you're in is specialist and value-based care. Why are they an important part of this, this picture? And what impact can specialists have on the success of value-based care contracts and the total cost of care?

Jay: Yeah, I think that's a that's a great question. And obviously we could spend a good amount of time on that. But if you want to boil it down, you know, from a financial success standpoint, obviously the majority of the dollars that are spent in health care are spent in specialty care. It's just essential for us to succeed at providing value-based care. To have specialists involved, not only involved, but also, you know, thriving in these types of models. So, if you look back at CMS and I, you know, I think we all agree and understand that CMS sets the market. And really more specifically, it's the center for Medicare Innovation, which right now is led by Liz Fowler, who's an amazingly gifted leader. In my mind, we've had the opportunity through our specialty society in Cardiology, the American College of Cardiology, to be in touch with her and meet with her and her team on a regular basis. And, you know, she's really outlined the importance of this continuum of care that obviously, the basis of which is primary care. And then the episodic bundles that are inserted or occur in patients' lives that come with that continuum of care and the bundles that would be, would handle that fit into this same kind of longitudinal continuum of care.

Jay: And then the patient cycles back to be in, you know, kind of a chronic disease model. Within that we're in kind of a unique market here in Maine, or at least as employed physicians. We have one primary ACO, but there's a lot of other markets that have multiple ACOs. In those markets, they want to find, you know, the catch term now is "high-value specialists." And how are they going to identify that? Well the move is already underway nationally around this. Some of it starts with CMS releasing their shadow bundle data, which we were able to obtain here at Maine Health. But this allows folks claims data on specialists to see where the value quotient is on, on certain specialists, and to the point where either different systems around the country or different consultants are now developing specialty report cards to see how specialists score on this continuum of cost versus quality. Liz Fowler really stresses more about making data accessible, so that ACOs and other entities know where individual you can get, right down to the individual provider level. How are they providing their care on a gauge of cost versus quality or value.

Jay: And then, you know, another thing that she stresses is collaboration with PCPs. And that might come in the form of things like e consults and really reducing duplication of care and maybe duplication of testing. And really when, where the rubber meets the road, I think from CMMi standpoint is to put some financial teeth behind that and really see which specialists are providing the high value, granted its high cost but high value care for these populations. So, I think that these things as they come about and we know as of April 10th, CMMi put out, Liz and her group, put out mandatory bundles. And I know the one that impacts us the most is bypass surgery. I know there are two different orthopedic bundles as well as there's a surgical around GI bleeding that are all mandatory bundles going into 2025.

Jay: This is here. It's not just on the horizon. These bundles will be with us. And CMMI is continuing in this direction. So it really is important for us to have experience, understand what the tools are that we need to be successful so that we can continue to provide the highest quality care for our patients.

Paul: Yeah. Thank you. You know, you mentioned a term I've heard tossed around before, shadow bundles. I think I know what that means, but can you describe what a shadow bundle is?

Jay: Yeah. And I might even ask for Sue's help. But in general, you can take a patient and their specific diagnoses. And Medicare is now, like, just released all the data around patient's billing data, basically. And you can then take this big mass of data and funnel it down and say, well, this is a heart failure patient. Let's take all the charges associated with heart failure for the year for them and see how these providers did in managing the patient's heart failure over the course of the year. Were they in the hospital, yes or no? If they were in the hospital, did they have, you know, over the course of their hospitalization, did they have any high-cost procedures? And what was the value of that? Meaning, what was their outcome? Did they end up in the hospital a month later again, or did they stay out of the hospital the rest of the year? That sort of thing. So that's my understanding again, that you'll be able to drill down to the individual provider with that data, and it might lead to more of an ability to come up with these provider type report cards in the future. Sue why don't you jump in? You're more of a specialist in this area than I am.

Sue: CMS did release shadow bundle data for all ACOs participating in MSSP and other ACO arrangements. Like Jay said, this will allow participants to look at an episode of care in the same way that they would if they were participating in a bundled payment program without being put at risk, but it will allow ACOs and others to look at provider performance, individual provider performance or specific populations of patients, whether it be procedural related or chronic condition and how they are managed. It can also allow you to look at post-acute care utilization and are there specific facilities that transition patients between acute care and back to primary care that do it very well? Allow you to look at things like readmissions or unintended emergency department utilization. So it does allow all of that data available without participating in the actual program.

Paul: I could see how that would be very useful to get all the data but not be at risk yet. Any words of advice finally, for other folks who may be interested in exploring bundles further? I guess that's going to be everybody since they're going to be mandatory, as Dt. Powers mentioned. So, what are words of advice?

Jay: Well, that is what they call a layup, right? You could start by coming to our symposium at the Value-Based Care MaineHealth Symposium. But seriously, obviously it starts with reading and cms.org is a good place to start. I think I would encourage specialists to look at their specialty websites, at least in cardiology we have a whole section dedicated to value-based care and really educating people from the ground up, terminology, where are we now? Where are we going? How do you succeed in these things. Those are available online. And then, there's more of this showing up in all of our publications, including the more generalizable publications like New England Journal, with their recent editorial on the Head program. The Head program is Global Budget for Health Care given to the state by the federal government. And I know that I think Maine decided to pass on that. But there are other states, such as Maryland and Vermont, that have been utilizing that type of approach over time, and who knows if we're heading in that direction as well.  I would say the internet, symposiums and national subspecialty organizations.

Paul: Excellent. Thank you. Sue. Anything to add?

Sue: I would just say, you know, continue to focus, if you're a clinical provider looking to get involved, just continue to focus on quality. Clinical quality, identify variation in care or opportunities to close any gaps around the system. Those readmission reduction efforts and avoidable ED utilization efforts are key. And then just learn from others experiences who have been through these programs. We found most of these lessons are transferable across different clinical bundles and lines of business.

Paul: Thank you. Sue Seekins, thanks for joining us. And doctor J. Powers, thanks for joining us. And as we've mentioned and alluded to, both of them will be leading a workshop on May 22nd at the ACOs Symposium on Value Based Care that's going to be in Freeport. And we will put a link to register for that symposium on our website. So once again, thanks to both of you.

Jay: Great. Thank you for having us. We appreciate it.

Sue: Thank you.

Heather: Thanks for listening to BACON this month. You can find all our podcasts on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have a question, comments or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org.

Mike: BACON is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.

Heather: See you next time.