Value-Based Reimbursement: The Banner Health Network Experience

B ecky K u h n , FACHE, a n d C h u c k L e h n S u m m a r y • Many organizations in healthcare are moving rapidly to adopt value-based reimbursement (VBR) models that reward value instead of vol­ ume. By shifting a significant percentage of clinical and financial risk from payers to providers, VBR programs can help reduce costs significantly, improve the quality of care, and increase efficiency. The experience of Banner Health Network (BHN) with VBR in commercial and government plans indicates that a large health system can transition to VBR with renewed focus on quality, cost efficiencies, population health management tactics, and member engagement. In December 2011, BHN was selected in a competitive bid process as one of 32 organizations to participate in a Centers for Medicare & Medicaid Ser­ vices (CMS) value-based demonstration initiative called the Pioneer account­ able care organization (ACO). As a Pioneer ACO with consistent and positive results, BHN, based in Phoenix, Arizona, has demonstrated that VBR can lead to results that are beneficial to the member, the healthcare organization, and the community. BHN has been a top performer in returning shared savings to Medicare while improving appropriate service utilization and performance on quality metrics. The development of simultaneous commercial ACO products was a re­ quirement of the Pioneer agreement with CMS, as well as a clear goal for BHN. The initial period of ACO partnership formation revealed an uncomfortable re­ ality: Payers and providers would need to collaborate and share information as never before. Further, many payers were uncertain about working closely with providers who were working simultaneously with other payers on similar part­ nerships. Before long, however, there were enough successful VBR arrange­ ments to allay these initial payer anxieties. Today, BHN has high-value network arrangements with nearly every major payer in Arizona. T l m > H C TV Becky Kuhn, FACHE, is executive vice president for com m un ity delivery at Banner Health in Phoenix, Arizona. Chuck Lehn is executive vice president o f strategic growth at Banner Health. m B e ck y K u h n , F A C H E , a n d C h u c k L e h n • 17
After moving steadily toward value- based reimbursement (VBR) for more than a decade, BHN has amassed a mem­ bership of about 350,000 covered lives. Moreover, 92 percent of BHN’s member­ ship is insured through a risk-bearing relationship. BHN’s strategies and tools for VBR range from clinical to technical. Engaged provider partners have been an essential component without whom success would not be possible. Banner Health care man­ agement teams working with our provid­ ers are focused on the development and imple­ mentation of evidence- based clinical practices across the enterprise to make sure that members receive the most expedi­ ent and efficient care with the fewest complications. Facility-based and community-based nurse case management allows members to re­ ceive the guidance, education, and clinical support they need to achieve the highest possible level of personal wellness and avoid unnecessary hospital admissions. Enabling technologies, such as telehealth, are showing great potential in creating virtual connections between patients and their caregivers. Claims data and an inter­ nal enterprise data warehouse drive popu­ lation health tactics and feed electronic health records (EHRs) to enable provi­ sion of the best possible care. Finally, a new area of focus for BHN is a post-acute strategy to ensure that the continuum of care does not end abruptly when members transition to post-acute care providers in the community. Although the move to VBR requires a commitment to meeting cost and qual­ ity benchmarks, integration of care at Enabling technologies, such as telehealth, are showing great p o ten tia l in creating v irtua l connections between patients and the ir caregivers. all levels, and a significant information technology (IT) infrastructure, BHN’s ex­ perience demonstrates a clear potential for organizations that successfully navigate the gap between a fee-for-service (FFS) world and VBR. I n t r o d u c t i o n After several years of slow but steady adop­ tion, VBR models appear to be on their way to replacing FFS as the predominant reimbursement system in US healthcare. McKesson (2014) estimates that VBR will overtake FFS by 2020, with 90 percent of payers and 81 percent of providers already using some mix of both. In the first score- card on payment reform released in March 2013 by the not-for-profit Catalyst for Payment Reform (2013), only 11 percent of payments to providers were not under an FFS model. One year later, the second report card (Catalyst for Payment Reform and Health Care Incentives Improvement Institute 2014) reported that 40 percent of commercial health plan payments were made through methods designed to improve quality and reduce waste (see Exhibit 1 for details about waste in the U S healthcare system). The U S Department of Health & Human Services (HHS20i5)is encourag­ ing the adoption of VBR by mandating that 30 percent of Medicare outlays by 2016 and half by 2018 be routed through alternative payment models such as ACOs and bundled payments. HHS (2015) also set a goal of tying 85 percent of all tradi­ tional Medicare payments to quality or value by 2016 and 90 percent by 2018 via programs such as the Hospital Value-Based Purchasing and the Hospital Readmis­ sions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals 18 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 3 2 1 2
Source: Health Affairs (2012). “ Health Policy Briefs: Reducing Waste in Health Care.’’ for alternative payment models and value- based payments. The Affordable Care Act created a num­ ber of new quality-based payment models, including ACOs, patient-centered medical homes, and new methods of bundling pay­ ments for episodes of care. In each pay­ ment model, healthcare providers are held accountable for the quality and cost of the care they deliver to patients, giving them a financial incentive to better coordinate care for their patients and avoid unneces­ sary expenses. Pay for performance (P4P) is emerging as the most commonly used model. Also known as value-based pur­ chasing, P4P measures quality by moni­ toring process outcomes, such as lowering blood pressure and counseling patients to stop smoking. In a 2014 McKesson report, payers using a mix of reimbursement models reported that the proportion of their business aligned with P4P would increase from 10 percent to 18 percent in five years. Providers using a mix of reim­ bursement models projected that their alignment with P4P would increase at an even greater rate from 9 percent to 21 percent in five years. Adopting a VBR model requires or­ ganizations to take into account clinical markers and best practices to ultimately produce better population-based out­ comes. Shifting focus to these long-range goals can be challenging and will require investment in contemporary healthcare IT and system-wide improvements in integra­ tion, such as a commitment to a common EHR platform that allows the dynamic exchange of patient data. BHN has moved toward VBR using several approaches. T l m > H 73 m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 19
Ba n n e r ’s Jo u r n e y to VBR Parent company Banner Health operates 29 acute, specialty, and critical-access hospitals in Alaska, Arizona, Califor­ nia, Colorado, Nebraska, Nevada, and Wyoming. In 2014, the system had $5.4 billion in revenue. Banner Health’s senior leadership strongly believes that VBR, supported by population health manage­ ment, has the potential to create greater sustainability in our nation’s healthcare system. To that end, we have developed a strategic plan and supporting infrastruc­ ture in accordance with that belief. Banner Health has the infrastructure for and 20 years of experience managing its own self- funded health plan in all the states in which we have operations. Banner Health was recently named the largest private employer in Arizona (Wiles 2015), so the opportunity to learn from our employee health plan members and their depen­ dents has been a significant benefit. We can apply new learning and capabilities to other types of arrangements and demon­ strate how these elements have played out in our own plans. In addition, the health system histori­ cally used a model that included taking on risk from several Medicare Advantage plans, but these plans and the self-funded health plan combined made up less than 5 percent of Banner’s business. To further prepare for VBR, Banner Health moved to­ ward a case-rate model of reimbursement (i.e., fixed payment for a defined episode of care), similar to diagnosis-related group reimbursement, by taking on more of the risk, especially with inpatient care. This model has provided incentives for deliv­ ering the right care in the most efficient way, preparing the patient for discharge, In 2012, B H N began entering in to contracts th a t carried significantly more fin a n c ia l risk than those it had entered into previously. managing resources and length of stay, and supporting care that would prevent avoidable readmission. BHN was incorporated in July 2011, designed specifically to be the vehicle for a collaborative model between Ban­ ner Health, independent physicians in the community, and physicians in the employed model used at Banner Medical Group. The network supports the assump­ tion of much more risk, making possible Banner’s participation as one of the origi­ nal 32 Pioneer ACOs in a demonstration program announced by the Centers for Medicare & Medicaid Services (CMS) in December 2011. Our integrated delivery network is composed of the Banner Health hospitals and ambulatory facilities, Banner Medical Group (employed providers), and two affiliated partners—Banner Physician Hospital Organization (BPHO) and Ari­ zona Integrated Physicians (AIP). These entities joined together with the goal of improving quality and the care experience while reducing costs for employers and the members we serve. In 2012, BHN began entering into contracts that carried significantly more financial risk than those it had entered into previously, especially relative to expecta­ tions around advancing quality measures, such as reduced avoidable admissions and readmissions and improved diabetic indicators. Today, nearly all of BHN’s book of business involves some degree of risk. To date, performance on various contracts has been uneven. Attributed populations in which member engagement and network utilization do not get traction can be chal­ lenging. Medicare Advantage and Market­ place plans are highly price sensitive. Yet, together, they have yielded a neutral effect financially, even after we consider the initial investments associated with the launch of a new division of the organization—BHN. 20 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 3 2 : 2
P i o n e e r ACO a n d C o m m e r c i a l ACO Pr o d u c t s In performance year i, more than 50,000 traditional Medicare beneficiaries were attributed to BHN. We became responsible for managing the health of these members on January 1, 2012. The Medicare Pioneer ACO is a value-based model designed to provide members with an improved patient care experience (including qual­ ity and satisfaction), improved health of populations, and a reduction in the cost of healthcare. In the first year, BHN demonstrated an ability to reduce hospital admissions, hospital length of stay, and the need for hospital readmissions by supporting beneficiaries in transitions when they were most at risk and in need of care and advocacy (see Exhibit 2 for more detail on performance year 1 results). Deploying nurse case managers and social workers was an important first step in developing a structure to better support the medical and social needs of the chronically ill benefi­ ciaries with complex medical needs who represented the top 5 percent of the overall spend. BHN proved to be a top performer EXHIBIT 2 Pioneer ACO First-Year Results in terms of shared savings compared with the results for other Pioneer organizations that year, returning $19 million in savings shared with CMS. L&M Policy Research (2013), an inde­ pendent research firm in Washington, DC, compiled a report for CMS titled Effect of Pioneer ACOs on Medicare Spending in the First Year. The report credited BHN’s focus on providing highly collaborative care— especially for chronically ill patients with complex medical needs—as a key to early success. Surrounding at-risk patients with supportive care, particularly during care transitions, was an important strategy that helped reduce hospital admissions and readmissions. Advanced IT was another important component of the ACO infra­ structure, giving providers more informa­ tion about the beneficiaries in their care. In performance year 2 (2013), BHN’s quality score reflected a gain of nearly 19 percent from the previous year, the result of an educational focus, monitoring of metrics, and provider engagement. As a top performer in the Medicare Pioneer ACO program for the second consecutive year, BHN shared savings of more than Reduction in overall hospital admissions Reduction in average length o f stay Reduction in avoidable hospital readmissions Reduction in high-tech imaging services 1 • Reduction in CMS paid amount per beneficiary ^ Banner Health Network m > H 7> m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 21
B H N has been able to develop strong and productive relationships w ith our payer partners. $15 million. This was possible as a result of delivering the right care, at the right time, in the right setting through more coordinated care, as well as having IT tools and a large enterprise that was able to set a new direction in support of value-based care. BHN is among a handful of organiza­ tions in the country that have established through early success that ACOs can improve the quality of care and the experi­ ence of care, as well as reduce Medicare costs. In the report released by CMS in late January 2014, BHN was one of two Pio­ neer ACOs that together achieved 41 percent of the total overall reduction in 2012 spending growth in this nationwide demon­ stration project. BHN is one of the remaining 19 Pio­ neer ACOs. In performance year 3, BHN returned more than $29 million in savings shared with CMS, and its quality score in 2014 improved by almost 10 percent from the preceding year. To date, results from performance year 4 have not been released by the Center for Medicare & Medicaid Innovation, but BHN anticipates similar results. Starting in 2012, BHN and Aetna, a diversified healthcare benefits company serving 36.4 million people, jointly of­ fered a shared-risk product, Aetna Whole Health, in Arizona. Lower prices incen- tivized members to stay in network, and BHN was able to generate savings through reduced hospital readmissions, expanded access to primary care physicians, and increased use of preventive screenings. In this way, both BHN and Aetna have a stake in the quality of the care, the cost, and the outcomes. After only the first full year of this relationship, BHN and Aetna announced that their accountable care col­ laboration resulted in a shared savings of approximately $5 million on Aetna Whole Health fully insured commercial member­ ship in 2013 and a 5 percent decline in average medical cost for members. In 2013, Aetna Whole Health plan members served by BHN attained the following: • Improvements in cancer screening rates, including cervical and colorectal cancer screening • Better blood sugar management in more members with diabetes • Reduction in radiology services of approximately 9 percent • Increase of almost 4 percent in the generic drug prescribing rate • Reduction of about 9 percent in avoidable admissions Aetna and BHN also saw savings and an improved medical cost trend among Aetna members in the ACO outside the Aetna Whole Health product. Nearly two-thirds of Aetna’s 47 commercial ACO agreements currently feature or expect to feature risk-sharing arrangements by 2015. In September 2013, Banner Health finalized a joint venture with Blue Cross Blue Shield of Arizona (BCBSAZ) that included the joint ownership of a Medi­ care Advantage plan formerly managed by a Banner Health legacy organization. As a result of this arrangement, which combines the capabilities of a payer and a provider, the membership in BCBSAZ Advantage nearly doubled from 23,000 to 45,000 in a two-year period. The success of this relationship has led to two other plans in the commercial marketplace: BCBSAZ Alliance and BCBSAZ Acclaim. 2 2 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 3 2 : 2
O v e r a l l Pa y e r Re l a t i o n s h i p s BHN has announced a variety of value- based relationships with payers, including UnitedHealthcare, Cigna, Humana, and Health Net. An important first step in these relationships was building trust and a true spirit of collaboration. Sharing data and working hand in hand from the sale of the product through the delivery of care was new territory for all parties. Ultimately, BHN has been able to de­ velop strong and productive relationships with our payer partners. The organization now has high-value network or attributed network contracts with nearly every major payer in our market, as well as an agree­ ment with a Medicaid plan. BHN also is the provider network for a variety of prod­ ucts on the Health Insurance Marketplace in coordination with Aetna, BCBSAZ, Cigna, Health Net, and Meritus. We work with each of our valued partners to de­ velop the tools and services that will bring the highest-quality care, service, and value to members. T o o l s t o S u p p o r t VBR BHN has used a wide range of VBR- related strategies and tools to improve quality, reduce costs, and achieve better population health management. Some of the most important factors in our progress are described here. Care Management Continuous clinical improvement has become an integral part of the care deliv­ ered throughout Banner Health as a result of its care management function. In 2001, Banner created a dozen functional teams that focused on patient safety, utilization management, and clinical data analysis, as well as a few clinical improvement efforts aimed at CMS core measures. The improvement process has evolved to include clinical consensus groups (CCGs) and Teams for Rapid Innovation and De­ sign (TRIaDs). To date, more than 50 teams, including 22 CCGs and six TRIaDs, are dedicated to improving clinical quality. The CCGs are multidisciplinary groups of physicians and other clinicians who examine emerg­ ing issues, research, and improvement opportunities in one specific clinical area. Many of these members are community providers who participate on a voluntary basis. TRIaDs focus on improving patient outcomes across the organization, espe­ cially within BHN’s membership. Each of these teams has a dedicated medical direc­ tor, clinical director, and process engineer. TRIaDs have focused accountable leadership for improving patient outcomes across the organization. The process engineer specializes in the development of metrics and design processes. These teams are now organized around health management for members and patients. The six TRIaDs focus on the following clinical areas: • Member needs assessment • Prevention/minor episodic care • Chronic care • Complex episodic care • Acute care • Complex chronic care The 22 CCGs serve the following clini­ cal areas: • Anesthesia • Behavioral health • Cardiology • Cardiovascular surgery • Critical care • Emergency medicine T 1 m > H 73 m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 23
Hospital medicine Infectious disease Medical imaging Neonatal intensive care unit (ICU) and newborn care Nephrology Neuroscience Oncology Orthopedics Palliative care Pediatrics Pharmacy and therapeutics Post-acute care Primary care Pulmonary care Surgery Women’s health involves a strategic approach, execution is key. Execution, has, in fact, become a core competence of our organization. We accomplish it by means of a three-step process: 1. Define the clinical practice (using clinical experts to study and determine practices that will significantly enhance care throughout Banner Health) 2. Design how it will be performed (including education and communication pieces) 3. Implement the clinical practice using project management tools and techniques O n e o f B a n n e r H e a lth 's core s tre n g th s is its in n o v a tiv e a p p ro a c h to re d u c in g th e k n o w n la g t im e b e tw e e n th e id e n t if ic a t io n o f a n ev id en ce -b ase d c lin ic a l p ra c tic e a n d its w id e a c c e p ta n c e a n d im p le m e n ta t io n . Banner Health also has 27 discipline teams ranging from noninvasive cardiology to medical/ surgical care and environ­ mental services to spiri­ tual care. These teams bring together leaders in a single discipline or service delivery area to standardize and improve clinical and operational performance system-wide by addressing care and service delivery; standards of professional practice; standards of patient care; and in­ formation, technology, and workflow. Over time, some of the earlier discipline teams have disbanded, making room for addi­ tional CCGs and TRIaDs to delve deeper into process improvement. One of Banner Health’s core strengths is its innovative approach to reducing the known lag time between the identification of an evidence-based clinical practice and its wide acceptance and implementation. Although clinical process improvement Clinical practices describe a spectrum of care that can be delivered to a group of patients who have a specified medical condition. On the basis of the strength of the evidence, these practices can be further categorized as expected (to be done every time) or recommended (based on the clinician’s judgment). Expected practices are developed from the highest level of evidence-based research or strong consen­ sus among practitioners across Banner. Telehealth and Enabling Technologies In 2006, Banner Health launched a tele­ health program based primarily around the Philips elCU. Two-way audio/video capabilities are now available in a large number of our ICU rooms across the orga­ nization. EHR information and physiologi­ cal data from the bedside monitors are streamed in a real-time feed to a remote monitoring center where Philips software is used to analyze the information and pro­ vide early signs of deterioration, allowing intensivists and critical care nurses to ob­ serve patients and notify on-site clinicians 24 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 32U
of potentially consequential changes in a patient’s condition. The telehealth system, called TelelCU, covers 650 acute care beds in five states in which Banner has operations. When the system is activated, patients can see and hear the remote clinician via a monitor lo­ cated across from their beds. The effect on quality of care and mortality rates has been stunning. Banner has augmented a strong bedside team with elCU technology and a 24/7 TelelCU team. This combination has saved Banner 46,435 ICU days and 1,890 lives in 2014, according to the APACHE IV actual-to-prediction metrics (Cerner 2013). Exhibits 3 and 4 depict the reduced length of stay and mortality, respectively. Banner’s relationship with Philips began in the ICU setting but has been extended to the ambulatory setting for in-home moni­ toring of the complex, acute population who may have difficulty traveling to medi­ cal appointments or receiving the care they need. More than 500 patients, primarily Medicare beneficiaries, are now accessing care through specially programmed tablets. These tablets, which we provide to program participants, allow them to initiate video consults with caregivers. This virtual care is coupled with live visits from health coaches and an ongoing primary care relationship. The program, which began in 2013, has demonstrated a 45 percent reduction in hospitalizations and a 27 percent reduction in the cost of care. Other areas of telehealth that are show­ ing great promise include telestroke care to connect stroke specialists with patients E X H I B I T 3 Longitudinal ICU and Hospital Length of Stay ICU Length o f Stay ------- APACHE Predicted <u zu y i .00 • “o ngn 0.60 • < 0.00 2009 2010 2011 2012 2013 Hospital Length o f Stay ------- APACHE Predicted s 120 .y 1.00 "U <D 0.80 S u 0.60 4-* < 0.00 2009 2010 2011 2012 2013 ^ Banner Health Network Source: Banner H ea lth and Philips. Note: APACHE is a reg istered tradem ark o f Cerner Corp. L igh t-b lue lines = Banner's ICU and hosp ita l length o f stay. "Tl m > H C 7° m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 25
EXHIBIT 4 Longitudinal ICU and Hospital Mortality % 160 ICU M ortality -------- APACHE Predicted 0 L4U 15 i-oo .y o.so TJ 2 0 0 9 2 0 1 0 2011 2 0 1 2 2 0 1 3 £ . Hospital Mortality -------- APACHE Predicted CO 0 '-4U ^ 1.20 £ 1 0 0 " O 0J 0.60 — *---------------- ___ 2 - , 0.40 3 0.20 ^ 0.00 2 0 0 9 2 0 1 0 2011 2 0 1 2 2 0 1 3 Banner Health Network Source: Banner H ea lth and Philips. Note: APACHE is a reg istered tradem ark o f Cerner Corp. L igh t-b lue lines = Banner's ICU and hosp ita l m orta lity . in the emergency department (ED), virtual support for our post-acute community partners to reduce unnecessary readmis­ sions, and virtual clinic visits for BHN members via a program connected to our 24-hour nurse triage service. IT Infrastructure Moving to VBR requires an EHR that can guide a healthcare organization and its providers in clinical excellence, pa­ tient safety, and operating efficiency. A fully developed EHR follows the patient through the continuum of care, enabling and informing caregivers in each setting. A 2003 Banner Health strategic initiative that became known as Care Transforma­ tion was a launching point for our orga­ nization toward this end. It addressed the 2 6 • F R O N T I E R S O F H E A L T H S E R V I C E S implementation of a comprehensive EHR across all Banner facilities and a separate but interfaced EHR across all of Banner’s employed physician practices. This effort involved combining elements of work re­ design, related and critical cultural change, and “hardwiring” of evidence-based clini­ cal practices to achieve the vision. Through those efforts, Banner has become recognized as a national leader in the use of EHRs, making patient care safer and more efficient. Banner Health’s broad suite of fully integrated clinical ap­ plications plays an important role for the organization. Twenty-one Banner Health facilities have achieved HIMSS Analytics Stage 7, currently the highest stage in the adoption of EHRs, according to HIMSS Analytics (2015), a wholly owned nonprofit M A N A G E M E N T 3 2 : 2
subsidiary of the Healthcare Information and Management Systems Society. HIMSS Analytics monitors and recognizes levels of EHR adoption and meaningful use in hospitals in the United States, Canada, and other countries. Banner Health hospitals use Cemer Corporation’s software for EHRs, employed providers in our organization leverage NextGen, and BHN-affiliated community providers have historically used a variety of EHRs, making care coordination across the provider network more complex. To begin to address this issue, we now offer affordable options for our affiliated pro­ viders who select one of two platforms (eClinical Works or Cerner Ambulatory) in an effort to reduce the number of systems that need to be integrated. In addition, we have bought blocks of licenses from eClini- calWorks that are being made available to providers who meet basic criteria and have an interest in transitioning their practices to align more closely with BHN. Aetna, through its Accountable Care Solutions division, offered ActiveHealth technology as our population health platform and physician registry. Active- Health has allowed us to integrate claims and clinical information from a variety of disparate EHRs, providing a holistic view of member encounters. The EHR is only the interface in the IT infrastructure, ensuring that providers have data at the point of care. First, a mech­ anism must be in place to collect, ingest, and analyze vast amounts of administra­ tive, claims, and other member data from payers and related sources. Until an organi­ zation can handle this influx of informa­ tion, it cannot fully succeed in managing the health of large populations. The inte­ gration of the data transformed into action­ able information is key to the success of an ACO. Much of BHN’s early success in VBR has been attributed to refining IT tools and data capabilities for better business intelli­ gence and care coordination triggers. C ase M a n a g e m e n t One of BHN’s initial efforts was the ag­ gressive recruitment of experienced nurse case managers. An important first strategy was supporting those high-risk members who accounted for 5 percent of the popu­ lation yet were responsible for almost 50 percent of expenses. We needed these nurses to be out in the community, identi­ fying underlying issues and advocating for the care needed to avoid possibly unneces­ sary repeated hospital admissions, thus reducing costs and improving our mem­ bers’ quality of life. The roadblock we found, as one might expect, was a lack of qualified case manag­ ers. Eventually, we created a program to grow our own case managers—an internal Case Management Academy available to Banner Health employees and even to community nurses who were interested in making a career change. These nurse case managers, working hand in hand with social workers, had an immediate effect on our most vulnerable members, many with multiple chronic conditions and some with social or behavioral issues that prevented them from receiving adequate care. However, we had not closed the loop in terms of case management because in-hospital and community case managers were working independently of one an­ other, with no procedures for patient hand- offs and no collaborative work on behalf of members. In 2015, we resolved this inter­ ruption in care coordination by means of a common database and a restructuring of the department, with a focus on geography instead of inpatient or outpatient status. ~n m > H 73 m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 27
ED de-escalation is another piece of case management support that has been an important asset to VBR. We recognized that many support programs and medical resources were available to BHN members that may have allowed them to receive care in the community and reduce avoidable hospital admissions. These services, which ED physicians and Banner case managers began to access on behalf of BHN members, included ambulatory case management, next-day appointments with BHN specialists or primary care physicians, skilled nursing care through community partners, home care services, and other outpatient resources. We pi­ loted this de-escalation work at several of our hospitals beginning in mid-2014. The concept found early measurable success and has been adopted on a wider scale. P o st-A cu te C are Post-acute care for BHN members has been a more recent focus. In light of the comprehensive nature of VBR relation­ ships, bur risk for the cost of care does not end when patients leave our care settings, yet our ability to have a direct impact does. It became clear that we had to develop partnerships in the community. We have identified skilled nursing and other post­ acute care providers who are enthusias­ tic about working with us to deliver on the Triple Aim goals of the Institute for Healthcare Improvement (IHI): improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of care. In April 2014, Banner Health sent a request for information to post-acute care providers asking for more detail about Through this in itia l transition to value-based care, Banner H ea lth has m ain ta in ed its f in a n c ia l health. their operations, quality, utilization, infec­ tion prevention, discharge planning, IT capabilities, and service standards. From these responses and subsequent in-person interviews, we selected a preferred network in September 2014 and continue to add providers. Results, driven primarily by a reduction in the length of stay in skilled nursing facilities, have shown a clear finan­ cial return, while allowing us to develop a more collaborative working relationship with these partners in care. For example, we are beginning to develop telehealth con­ nections with various sites, allowing them to access our remote clinicians when they have questions about a change in patient status or uncertainty about whether hospi­ tal readmission is needed. Im p ro v e d Payer M ix and Expected G ro w th Through this initial transition to value- based care, Banner Health has maintained its financial health, which suggests that systems can survive and even grow as they pursue VBR and the IHI’s Triple Aim (see Exhibit 5 for data on Banner Health’s growth in value-based volumes). Attracting new members is a founda­ tional theme in Banner’s long-term strategy and the new defining metric for our future growth. To gain the membership needed to reach the tipping point—the point at which overall growth is sufficient to offset invest­ ments in population health infrastructure, reduced utilization, and lower margins on services provided—in population health and financial growth during times of trans­ formational change in our industry, Banner is pursuing these goals: • Provide a great experience that meets our consumers’ expectations of service and convenience 28 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 32:2
E X H I B I T 5 Growth in Value-Based Volumes 350,000 300,000 250,000 200,000 150,000 100,000 50,000 2010 2011 ? Commercial Pioneer ACO ^ ------------1------------ ^ ------------1 ^ ? 2012 2013 2014 Banner Employee Plan ? Medicare Advantage • Improve health management performance in Medicare, Medicaid, and commercial business through a variety of population health approaches • Embrace the fact that payment will be based on the outcomes we can deliver, and only when we meet agreed-upon benchmarks related to care, service, and spend • Manage costs and maximize operational efficiency • Package all of these capabilities together into saleable products and services with clearly defined value propositions • Focus on the acquisition of members in a variety of areas that offer the opportunity to share in the risk and the reward of population health management Care management infrastructure, IT in­ frastructure, enabling patient care tech­ nologies, community and inpatient case management, and post-acute care partners and support—we have found these tools to be the foundation of our transition to VBR. Many functional areas have con­ tributed to our journey; however, the coordinated work in these areas of our or­ ganization has been essential to our early development as an ACO and our ability to be successful in a VBR environment. Lessons Learned T l Banner Health’s journey to VBR has yielded several important lessons, some of which may be transferable to other health systems: E A • Fully engage your providers. Physicians will adapt to VBR principles if they are invited to participate in specific H clinical and financial models, such as the patient-centered medical home, bundled payments, shared savings, or C other mechanisms that align quality, service, and cost goals. BHN has identified these keys to encouraging 73 full physician engagement: m B e c k y Ku h n , FACHE, a n d C h u c k L e h n • 29
- Accountable care is appealing because it is the right clinical thing to do. Emphasize that all standards and expectations are a result of evidence-based medicine. Provide data that illustrate the impact of improving care. - Offer the path of least resistance. Make adherence to your preferred processes easier than other alternatives. Communicate key information to providers in support of value-based decisions. - Encourage use of comparative information at all levels. Benchmark administrative and provider data to other organizations and providers, highlighting the deviations and outliers. - Invest in the growth of physician leaders. • Finance, data infrastructure, and administrative work will dominate your time and attention during the start-up phase. • Develop specific strategies to manage out-of-network costs. • Small populations increase the risk of random variation, so have a plan to grow. • Post-acute care can make or break your performance. • Data are everything. The entire VBR concept depends on extensive and accurate data, so generating and synthesizing those data must take priority. Adequate resources must be devoted to this task. • Clinical performance, innovation, and member engagement are the keys to long-term success of VBR. The entire value-based reimbursement concept depends on extensive and accurate data. • Identifying specific areas of financial, quality, or service improvement is a good way to align the interests of all parties toward a common goal. • Organizational commitment and the cultural shift necessary to support VBR do not happen overnight—or by accident. Be sure you have the support of your full enterprise, or you will not find success in this journey. C o n c l u s i o n BHN was an early entrant in the health­ care industry’s move toward VBR. Our experience illustrates the challenges and potential rewards that other providers may encounter as they transition away from FFS and toward payment based on out­ comes and quality metrics. This account of our early experience demonstrates that a large, integrated health system has the ability to transform itself to meet a changing reality—the move from FFS to a VBR environment. We now know that it is possible to be suc­ cessful in this model. Although we are strategically well positioned to move forward, our work and transition are not complete. BHN is still navigating the course of this journey. We are constantly learning from others, refining our processes, and evaluating new opportunities. We continue to confirm for ourselves that population health manage­ ment within an integrated delivery system is the best vehicle to meet the IHI’s Triple Aim and ensure the sustainability of healthcare for future generations. Re f e r e n c e s Catalyst for Payment Reform. 2013. “Na­ tional Scorecard on Payment Reform 2013.” Accessed June 4, 2015. www. catalyzepaymentreform.org/images/ documents/NationalScorecard.pdf. 30 • F R O N T I E R S O F H E A L T H S E R V I C E S M A N A G E M E N T 3212
Catalyst for Payment Reform and Health Care Incentives Improvement Institute. 2014. “Report Card on State Price Transparency Laws.” Published March 25. www.catalyzepaymentreform.org / images/documents/20i4Report.pdf. Cemer. 2013. “Cemer Research Shows How APACHE Outcomes Properly Analyzes ICU Performance for Benchmarking.” Published July 2. www.cemer.com/ Cemer_Research_Shows_H ow_AP AC H E_ Outcomes_Properly_Analyzes_ICU_ Performance_for_Benchmarking/. Health Affairs. 2012. “Health Policy Briefs: Reducing Waste in Health Care.” Pub­ lished December 13. www.healthaffairs. org/healthpolicybriefs/brief.php?brief_ id=82. HIMSS Analytics. 2015. “Validated Stage 6 & 7 Providers List.” Retrieved September 20. www.himssanalytics.0rg/stage7. L&M Policy Research. 2013. Evaluation of CMMI Accountable Care Organization Initiatives: Effect of Pioneer ACOs on Medicare Spending in the First Year. Published November 3. http://innovation, cms. gov/files /reports / pioneeracoeval reporti.pdf. McKesson Corp. 2014. “The State of Value- Based Reimbursement and the Transi­ tion from Volume to Value in 2014.” Accessed June 4, 2015. http://mhsinfo. mckesson.com/rs/mckessonhealthsolu tions / images /MHS-2014-S ignature- Research-White-Paper.pdf. US Department of Health & Human Ser­ vices. 2015. “Better, Smarter, Healthier: In Historic Announcement, HHS Sets Clear Goals and Timeline for Shifting Medicare Reimbursements from Volume to Value.” Published January 26. www. hhs.gov/news/press/2015pres/01/ 20150126a.html. Wiles, R. 2015. “Arizona Republic 100: State’s Largest Employers.” Published April 27. www.azcentral.com/story/ money/business/2015/04/19/arizona- republic-1 o o-largest-employer s / 25462291/. > H m B e c k y K u h n , FACHE, a n d C h u c k L e h n • 31
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Value-Based Reimbursement: The Banner Health Network Experience

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