From the May 2016 issue of HealthCare Business News magazine
By Neil Smiley
Most hospitals have been leveraging analytics to address a variety of operational needs from procurement to revenue cycle management, and patient risk analysis.
However, value-based payment models are blurring the traditional domain boundaries for analytics. Hospitals now need to link data sets that have not previously been brought together as hospital profitability and clinical outcomes are increasingly interdependent. Hospital data alone is also insufficient. Analytics need to extend visibility beyond the walls of the hospital to include data from payers, physician groups, post-acute care providers and community-based partners.
Beginning in April 2016, CMS moved to bundled payments for hip and knee replacement surgeries for approximately 800 hospitals that reside within one of 67 geographic areas. The bundled payment includes the hospital procedure and all costs incurred in the 90 days following discharge. Affected hospitals are now thrust into the role of a network convener, responsible for cost and outcomes for the entire 90-day episode of care. It is widely expected that CMS will continue to expand the bundled payment program to include other geographies and procedures. Other payers are following suit.
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Bundled payments and other value-based reimbursement models require hospitals to embrace a comprehensive and integrated approach to analytics in three key areas:
• Network Design
• Network Management
• Network Interventions
In a fee-for-service model, hospital financial responsibility ends at discharge. However, with new value-based reimbursement models, hospitals are on the hook for care episodes that typically extend 30 to 90 days after discharge. To make matters more challenging, most hospitals do not have their own post-acute care resources. For successful outcomes hospitals will need to collaborate with financially independent post-acute care providers. And yet, hospitals will increasingly bear responsibility for both financial and clinical outcomes.
Hospitals need to start by getting a handle on the referral patterns and performance of existing post-acute care partners, particularly for conditions and care pathways involved in value-based care reimbursement models. Most hospitals have found that relying on self-reported data from post-acute care providers is usually insufficient, as there are too many data visibility gaps and too much inconsistency in measurement methods.