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Big successes in a Penn. bundled-payment program

Integrated Patient Relationships for Success with Bundled Payments

Clinician-led Design Incorporates Human Needs Across Episodes of Total-Joint Replacement

CMS is pushing providers to fully integrate care to improve patients’ experience and outcomes, which can also decrease the overall cost of care episodes because of faster recoveries and fewer readmissions.

Cambridge Management Group (CMG), working with colleagues at Pyxera, responded to this imperative in a recently completed year of helping PinnacleHealth and other healthcare providers in central Pennsylvania redesign their total-knee-replacement (TKR) episodes.

The work was initiated within PinnacleHealth’s participation in the CMS Bundled Payment for Care Improvement (BPCI) program as well as within a pilot initiative with a large employer involving total knee replacement. The aim of CMS (and other payers) is to achieve better, more integrated health services while saving money – in the case of CMS, the taxpayers’ money.

Among the outcomes:

  • Identifying and developing physician leaders in context of the TKR design team, a process that can serve as at least a partial template for bundled-payment programs in other service lines.
  • Establishing personal/professional links with clinicians across the care episode – essential for care and cost coordination, empathy and higher morale in the working environment.
  • Demonstrating advanced market methods important in attracting a large commercial payer.

The work was suggested by CMG and sponsored by Dr. George Beauregard, chief clinical officer at PinnacleHealth. Dr. Beauregard saw an opportunity to demonstrate a safe, early-learning collaboration with the Orthopedic Institute of Pennsylvania (OIP); Arlington Orthopedics; perioperative orthopedic staff at Pinnacle, and selected post-acute-care providers.

Dr. Beauregard, other Pinnacle leaders, OIP and Arlington saw the potential of redesigning certain aspects of care delivery within the TKR arc of care to improve the patient experience and outcomes, gain additional process efficiencies, improve communication between all stakeholders involved in a TKR episode and reduce costs. The BCPI program was a laboratory for peer-to-peer learning and innovation for use with all TKR payer groups and, eventually, other bundled episodes of health services. (Dr. Beauregard recently became the chief physician executive at St. Luke’s Health Partners in Boise.)

The work was led by Dr. Jack Frankeny, CEO of OIP. Dr. Frankeny saw an opportunity to demonstrate clinician-led design across the episode to re-calibrate the TKR value-proposition (high quality and easy access) to consistently incorporate human-centered features. At the outset, the TKR service was a well-regarded and busy regional service navigated by resourceful patients and families. The objective was to integrate siloed services within the program for a seamless experience preferred by patients, families and providers.

The lens for focusing the work, evidence-based-design (EBD) methods, was provided by Tad Simons, Ph.D., and Don Westwood, founders and partners in Pyxera, in collaboration with CMG. They have nationally recognized expertise in designing systems, bringing evidence-based design to healthcare networks as their staffs learn to manage interactions across newly integrated services. EBD is one pathway to embed skills/values for adaptive, empathetic care coordination — the essential competence to win with bundled payment.

Participants called the experience very successful, and see it as offering guidance for bundled payments in other service lines, such as hip replacements and heart-bypass surgery.

The work first required interviewing clinicians across the continuum of health services to understand the interactions between them. At Pinnacle and most other systems, individual clinicians have tended to have remarkably incomplete knowledge of the identities and work of colleagues in other parts of a patients’ care. The lack of integration has hurt outcomes in some cases, undermined collaboration between clinicians and between clinicians, patients and family caregivers and led to expensive inefficiencies, including duplication of services.

Dr. Simons led interviews of key players across the course of a patient’s care that provided information, insights and, occasionally, inspiration for designing a human-centered experience enhancing the effectiveness, efficiency and low cost already present in the TKR service.

The basic sequence in the project was:

  • Assessing patients’ pre-op readiness for surgery to reduce complications and prepare well ahead of time for the discharge to home.
  • Working with patients and the hospital’s primary-care network to improve patients’ readiness for surgery.
  • Visiting patients’ homes to ascertain social factors, especially the capacity of family caregivers, to help streamline discharge.
  • Preparing patients for productive post-op physical therapy by connecting early to the physical-therapy team.
  • Coordinating in-hospital plans of the surgeon, anesthesiologist and unit staff to enable discharge after 36 hours.
  • Coordinating and enhancing care between multiple providers preceding the first surgical follow-up visit.
  • Coordinating care between multiple providers and improving outcomes during rehabilitative therapy through the end of care.

The project’s leaders are enthusiastic about the experience. Dr. Simons listed the pilot’s key achievements as:

  • “Better coordination and planning with services outside the hospital — for example, physical therapy, occupational therapy and home visits.’’
  • “A deeper recognition of the importance of patient selection and preparation.’’
  • “Spawning excitement among clinical staff about using design thinking for new process development.’’

Dr. Frankeny, the Orthopedic Institute CEO, called the bundling project a “crash course in value-based care for our orthopedic surgeons who were born and raised in the fee-for-service model. They also learned how important collaboration is with all caregivers throughout the health-service episode. It’s the only way to win in the bundled environment.’’

Dr. Frankeny lauded the Pinnacle administration’s transparency about costs, saying that it helped build trust among surgeons and other clinicians.

He noted, as did Dr. Beauregard, the initial strong opposition of some surgeons, who tend to be “Type A individuals who want to win.’’

But, he said, “Confront difficult docs with evidence {about cost and medical outcomes} and they will listen. And they have come to understand they will have to learn to live with a risk-and-value-based system because it will have a direct impact on their income and in how they run their practices. They must do something or something will be done to them. They understand that the data will compel change in any case.’’

And as part of the brave new value-based world, Dr. Frankeny noted, there’s a new imperative to go with the cheapest procedure if there’s no evidence that it produces worse medical outcomes.

Everyone in the project came to understand more than ever before the importance of the interactions between clinicians and other caregivers along all steps of a patient’s care.

Dr. Beauregard, the former Pinnacle chief clinical officer, noted the project’s victory over skepticism and outright opposition. The first reaction of one surgeon leader was “over my dead body,’’ he halfway joked. But physicians changed their minds as Dr. Simons demonstrated the strengths of the design process in improving outcomes, efficiency and collaboration, even as the doctors were reminded of the inevitability that the CMS — armed with more precise medical-outcome and cost data – would make bundled payments mandatory in multiple service lines.

And, in any event, “fixed price points will be beaten down in the commoditization’’ as CMS caps the prices of many procedures.

Dr. Beauregard said of the bundled-payment project: “Change is mandatory. We’re facing reality.’’

If the Pinnacle pilot program is any indication, that reality will be more than tolerable.

To elaborate on the success factors noted at the top of this article:

  • Executive and physician sponsors have used credibility and energy to enlist previously unconnected hospital executives, physicians and other patient-facing staff and a wide-range of other provider-partners.
  • Physician leaders with clinical and organizational gravitas have helped guide busy colleagues (across the episode) as they transform daily work while rebalancing operations and finances.
  • A process (lens) useful now and in the future to enlist and focus the deep and diverse competencies of the full range of providers, patients and families and to inform and inspire the clinician-led design team.


The world after Meaningful Use


While acting CMS head Andy Slavitt said this week  that the Meaningful Use program, at least as it existed, will end,  providers will still be held accountable for using technology in patient care.

The end of Meaningful Use  as we know it means no more incentives  (as opposed to penalties) from Medicare for adopting it,  although Meaningful Use-style incentives  will continue for Medicaid.

Still, an eligible  Medicare provider who fails to attest to Meaningful Use will  face a penalty.

However, Becker’s Hospital Review says that the recently passed blanket “hardship exemption permitting any Meaningful Use participant to apply for an exemption from Meaningful Use penalties in 2017 may bring the reimbursement penalties that year close to zero.”





CMS announces new Medicare ACOs


The Centers for Medicare & Medicaid Services (CMS) has announced 21 new participants in Medicare Accountable Care Organization (ACO) initiatives designed to improve the care patients receive  and lower costs. With this announcement, ACOs now represent 49 states and the District of Columbia.

Looking for payment models for community health


Because Cambridge Management Group has done considerable work in community/population health, including in addressing the social determinants of health, especially in the Pacific Northwest, this article in The New England Journal of Medicine caught our eyes.

The authors  of the article, headlined “Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid,” write:

“As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.

“Some encouraging innovations have emerged. Catalyzed in part by statewide all-payer delivery-system reform and the growth of value-based or shared-risk payment models, some purchasers and providers of medical care have found innovative ways to support high-value community-focused interventions. For example, Hennepin Health, a county-based Medicaid managed-care organization in Minnesota, has reduced emergency department visits by 9% by using housing and community service specialists who are part of a tightly integrated medical and social service system.”

“To accelerate the development of a scalable delivery model for addressing upstream determinants of health for Medicare and Medicaid beneficiaries, CMS recently announced a 5-year, $157 million program to test a model called Accountable Health Communities (AHC). …{T}he test will assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”

“The AHC model reflects a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system. The AHC test will improve our understanding of whether savings can materialize when upstream factors are addressed through collaboration among stakeholders who are accountable for the health and health care of their community.”

MU hardship exemption soothes providers and CMS



Herewith a look at how letting eligible hospitals and  other providers participating in CMS’s Meaningful Use  electronic health record apply for a blanket hardship exemption to avoid reimbursement penalties will  help CMS as well as the providers.

Congress  recently passed bill S. 2425, which lets any eligible hospital or  clinician to apply for an exemption for 2017 from MU penalties. Previously, hospitals and professionals had to meet certain criteria  to apply for the exemption.

As Becker’s Hospital Review noted, the hardship exemption “offers an obvious respite {to providers} in their journey to Meaningful Use attestation. Not only does it stave off penalties, but it softens the burden of meeting the newly released stage 3 requirements….”

The news service added: “What’s more, CMS eases the burden on itself with this blanket exception. Since the agency no longer has to review hardship exemptions on a case-by-case basis, that eliminates thousands of applications it needed to individually review….”


Plan to discourage routine prostate-cancer screenings fought


There has been a lot of pushback to a proposed plan by the Centers for Medicare & Medicaid Services to penalize doctors who order routine prostate-cancer screening tests. It’s part of a federal effort to define and reward quality in health-care services and to advance evidence-based medicine.

The Wall Street Journal reports that some complain that the measure “would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.”

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” David Penson,  M.D., chairman of public policy and practice support for the American Urological Association,  told the WSJ. The association urged  the CMS not to implement the proposal.

The U.S. Preventive Services Task Force  opposes routine screening for prostate cancer for men of any age because, it says,  the benefits don’t outweigh the harms.




CMS has been underpaying duel-eligible health plans


Responding to complaints from health plans questioning the accuracy of the CMS template for predicting costs, the agency has disclosed that it has been underpaying health plans that enroll many people  dually eligible for Medicare and Medicaid. CMS says it will modify its  risk-adjustment model to make up for the underpayment.

The CMS has been using a  model (called the CMS-HCC) to calculate risk scores, using health status in a base year to predict costs in the next one. Modern Healthcare reports that “scores drive adjustments to capitated payments made for elderly and disabled beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration programs. ”

CMS bundled-payment plan seen driving up costs


An X-ray showing a right hip (left of image) has been replaced, with the ball of this ball-and-socket joint replaced by a metal head set in the femur and the socket replaced by a white plastic cup.

He writes that as “now designed, the mandatory ‘comprehensive care for joint replacement’ payment model could encourage many of the program’s 800 hospitals (and their affiliated orthopedic surgeons) in 75 metro areas to perform more of the pricey procedures on arthritic seniors, not less. If that happens, it will be a perverse twist on the old saying: What the CMS makes on each bundle will be lost on volume.”

“In fact, {the CMS plan} would provide a powerful incentive for hospitals and surgeons who make money on the bundle to do as many as possible. No wonder consultants, physician management firms and medical suppliers are touting their ability to show hospitals how to make money under the bundled-payment program. Many are even willing to share the risk.

“There is an alternative. Hospital systems could offer the ‘watchful waiting’ strategy if the CMS would give them a comprehensive payment to cover the patient’s condition—in this case, severe arthritis of the knee or hip.”

How ACO ‘triple whammy’ undermines Triple Aim


This HealthAffairs posting describes how a “triple whammy” undermined the Triple Aim. It looks at the experience of Dartmouth-Hitchcock Health, the pre-eminent academic health system in northern New England, which recently decided to bail out of  being a Pioneer Medicare Accountable Care Organization.

The “Triple Whammy” discussed in the piece include:

A Flawed Risk-Adjustment Methodology

A Moving And Flawed Target

Identical Incentives Regardless Of Baseline Performance

The authors concluded:

“DH {Dartmouth-Hitchcock} did not make the decision to leave the Pioneer program lightly. A leader in the adoption and application of ACO principles, DH is committed to pursuing high-value population-based care through continuous quality improvement and a relentless focus on cutting waste from health care delivery by engaging providers and payers, waste that is perhaps more difficult to identify and reduce from within a very low-cost environment.”

“To meet its ambitious goals, CMS must provide fair incentives that are large enough to encourage more healthcare systems to enter new reimbursement models and attract and retain providers in both high- and low-cost settings; otherwise, unrestrained fee-for-service cost growth will continue and the full promise of “accountable care” will remain unrealized.

“CMS must rectify the flaws in the Pioneer model so that high-cost ACOs are rewarded for meaningful improvement, and low-cost ACOs—that have already benefited CMS and Medicare beneficiaries by applying ACO principals over the long term and whose ability to generate cost savings is likely to be modest—are rewarded and not punished while demonstrating improvement.”




Fee-for-value leader Dr. Beauregard joins CMG


George Beauregard, D.O., has joined Cambridge Management Group (CMG) as a senior adviser. Dr. Beauregard has been a leader in moving hospitals and physicians into the new world of fee-for-value care.

He has 20 years of experience in private practice in internal medicine and vast experience with pay for performance; performance- and risk-based contracts involving commercial and Medicare payers; EMR/HIT implementation, and Accountable Care Organization and Bundled Payment development.

In his recent role as senior vice president and chief clinical officer for the PinnacleHealth System, based in Harrisburg, Pa., he worked closely with the clinical and administrative leadership to help PinnacleHealth achieve enterprise- wide success in successful CMS Accountable Care and Bundled Payment initiatives; quality and performance improvement; clinical integration, and HIT optimization. This helped lead CMS to welcome RiverHealth ACO, of which PinnacleHealth is a founding member, into the 2014 Medicare Shared Savings Program.

Prior to joining PinnacleHealth, in September 2012, Dr. Beauregard was president and chief medical officer of Southcoast Physicians Network, in Massachusetts.  His leadership helped gain Southcoast admission into the 2013 Medicare Shared Savings Program.

Before that, he was co-founder, in 1996, of Primary Care LLC, the largest independent community-based primary-care-physician network in eastern Massachusetts. Dr. Beauregard guided a merger of that entity with Tufts Medical Center in 2005 to form the New England Quality Care Alliance (NEQCA), where he then served as chairman of the board for four years. He also was trustee of Tufts Medical Center Physicians Organization Inc.

George Beauregard is a graduate of the University of New England College of Osteopathic Medicine. He has been awarded Diplomate Certificates by the American Board of Internal Medicine and the National Board of Osteopathic Medical Examiners.


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