A large multistate health plan enables successful value-based program expansion

Client background

A large multistate health plan covering over 15 million lives.

The business challenge

In 2016, Centers for Medicare and Medicaid Services (CMS) launched the Comprehensive Care for Joint Replacement (CJR) model for full hip and knee replacements, which has become one of the most widely adopted CMS bundled payment programs. According to CMS.gov, there are currently 465 inpatient prospective payment (IPPS) hospitals in 67 different MSAs participating in this program. Our client was pursuing a pilot retrospective Episodes of Care program for full hip and knee replacement procedures similar to CMS’ CJR model. Their goal was to encourage providers across an integrated health system to work together to deliver high quality, coordinated care for patients while lowering overall cost and market variability of full hip and knee replacements. However, many of the critical business processes and systems needed to achieve this program goal did not exist. To launch a successful program, our client needed to:

• Identify an Episodes of Care bundling vendor: Our client sought out a vendor that would allow them to utilize an existing solution for core bundle builds and be able to scale beyond the pilot. This required a strong vendor partner that could support both PROMETHEUS and Bundled Payments for Care Improvement (BPCI) bundling methodologies, and had proven experience with a wide range of episode bundling types beyond knee and hip replacements, such as maternity, cardiac and chronic conditions.
• Embrace a new value-based reimbursement program type: Our client already had a strong Accountable Care Organization (ACO) program, and desired to expand its portfolio of value-based programs to include Episodes of Care (EOC) based programs, extending their existing ACO-focused platform functionality wherever possible. This implementation required our client to understand complex business rules that define bundles, develop quality measurement methodologies and scoring systems for specialists participating in EOC and determine how to value and transact the incentives required for this program.
• Update legacy systems and processes: In order to launch this pilot, our client needed new technologies and business processes that could be integrated into the existing value- based program platform maintained by their value-based operations team. With a rapidly growing ACO program and no new operations resources readily available to support this new program, it was crucial that the new technologies and processes selected for the EOC program to be seamlessly and efficiently integrated into the existing value-based program platform and processes.

The Baker Tilly approach

Baker Tilly provided program and project management guidance, organizational change management services and experienced project execution resources to help our client implement the pilot EOC program.

• Defined organization structure, processes and responsibilities: Baker Tilly provided change management leadership to define future state processes, with a heavy focus on integrating new EOC processes with existing ACO processes. The impacts of change were carefully analyzed to ensure the solution met enterprise-wide production control requirements, and a communication plan was created to help manage the organization and stakeholders through the change.
• Integrated new technology into an existing platform: Helped develop and design a multiple phase implementation strategy based on pilot program needs. The initial implementation phase required several solution components, including:
  
• Enhancements to an existing application to support the Network contract configuration needed to scale the value-based program platform from ACO to EOC.
• Development of a new custom SAS solution used to identify EOC program eligible members that can expand across multiple episode types.
• Configuration of a secure data exchange that enables data to be exchanged with the selected third-party vendor to identify eligible episodes and analyze trends for future episodic bundling programs.

Phase two focuses heavily on a custom solution that measures each EOC participating providers financial and quality performance against unique contractual arrangements and the reimbursement of incentives to providers who achieve contract targets.

• Program and project management: Baker Tilly provided project management leadership around agile approaches to project execution, decomposition of scope, creation of detailed project plans and execution tracking. Created design documentation, created and executed test plans, constructed specific system components, tracked defects and supported release management.

The business impact

With Baker Tilly’s help, our client successfully scaled their value-based program platform to integrate new processes and systems, which allowed them to launch their pilot EOC model with two major provider groups in across multiple states. As a result, our client has achieved:

• The ability to quickly respond to requests from large employer group RFP’s expecting EOC program deployment and the related cost containment benefits.
• Improved financial cost transparency: Our client now has the ability to monitor and report the cost and utilization of full hip and knee replacement surgeries and measure improvements over time.
• Improved processes: New business processes are executed on an ongoing basis to define EOC populations, exchange data with a third-party vendor and manage provider incentives.
• Improved technologies: Significant demand to expand existing value-based programs to new episode types continues. The technologies and processes selected by our client to use for this program have positioned our client to easily execute financial modeling for new episodic bundling programs and integrate new bundle types into existing production process.

For more information on this topic, or to learn how Baker Tilly specialists can help, contact our team.