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With the advent of Bundled Payments for selected procedures and conditions, providers and institutions must collaborate to meet both cost and quality targets. No longer will each provider bill and receive payment separately for services when these bundles become mandatory—as most experts believe will happen.
All providers participating in a set “bundled” price must focus on coordinated performance improvement or face penalties. Key to that effort: a Clinical Data Registry (CDR) that tracks patient outcome data over time and pinpoints success or failure of interventions.
CDR Performance Improvement Tools Are Essential for Bundled Payments Success
The CDR fulfills two fundamental roles: First, since 2014, CMS has authorized CDRs to report all-patient performance of quality measures and to develop distinct custom measures that will enhance provider quality. Second, a CDR now may function as a Specialized Registry under Meaningful Use (MU) to receive public health reported data; this, combined with its future role under MIPS, creates a critical foundation for revealing outcomes over time, conducting research and achieving performance improvement.
When it comes to Bundled Payments, the CDR has two significant tasks. First, it must report on measures for performance purposes, and a CDR can customize measures that will focus specifically on improving the efficiency and effectiveness of care delivered to patients. The measures must be crafted to improve cost, patient care, outcomes, efficiency and patient satisfaction. These measures should achieve the following:
- Evaluate costs against norms and other providers, and evaluate care delivered under Bundled Payments versus traditional reimbursement;
- Determine alignment between patient expectations and outcomes;
- Assess and document patient engagement and commitment;
- Measure and enhance the coordinated care delivered by Bundled Payment participants.
Second, because of the greater volume of data available to Clinical Data Registries from multiple sources under MU and MIPS, as well as access to Medicare claims data, CDR analytics provide a substantive foundation for performance improvement. The CDR is well suited to identify variations in care and investigate specific processes and outcomes. This assessment is enhanced by more discrete data available via custom measures, including patient-reported outcomes that can facilitate research on treatments not available under typical clinical trials.
How to Deploy CDR Tools For Cost and Outcomes Improvement
When a patient is identified as potentially being part of a Bundled Payment, two initial steps will predict success: first, conducting a risk assessment of the patient to determine a true targeted cost; second, assessing the patient’s goals or expectations. Both of these processes can be established as measures or analytics to determine the success of a Bundled Payment on a patient-by-patient basis. Since success can only be determined by evaluating the variation in these two metrics after the event and along a continuum of time, a CDR is uniquely suited to facilitate this evaluation.
Let’s take a look at how this works for a patient who needs a pacemaker. A Bundled Payment for the pacemaker implant should have a predicted cost based on the patient’s past and current risks, as well as a set of patient expectation outcomes that should be part of the pre-implant discussion with the provider. Pacemakers vary in functions and costs. If a patient receives a “one size fits all” device, but wants to maintain a vigorous exercise regimen, that patient may be quite unhappy with limited heart-rate modulation options. The specialty care physician’s failure to discuss options in advance of the implant will also bring scrutiny on his or her financial motivations.
The Bundled Payment target cost should be established only after ensuring that both clinical risks and individual patient needs are captured consistently. A CDR can implement process measures to facilitate both institutional and specialist participation, capturing data that has historically not been included (for example, patient functionality goals). Key to ensuring that the individual patient’s specific needs are met, the lead proceduralist should be identified for every bundle. It may be a challenge to measure how consistently pre-procedure discussions take place, but this important data can be captured with CDR tools.
Why go to all this trouble? With Bundled Payments, payers become even more vigilant about quality of care because of the financial incentive to do less. It is essential to ascertain a patient’s goals and expectations at the outset of any intervention. If the provider is unaware of or ignores these expectations, the quality of the care will be undervalued and unappreciated. What are the patient’s short-term and long-term goals? Does he or she believe these goals have been met? These are significant outcomes that must be tracked and assessed. This process also helps to identify patients with unrealistic expectations, which must be discussed, corrected and documented.
Such patient-centric processes empower the patient and put the patient-specialty physician partnership at the center of Bundled Payments, where it belongs. Identifying the patients who have the greatest variance in costs, both positive and negative (from the mean and from the CMS payment), can enable process improvements with feedback from all care providers throughout the Bundled Payment’s duration. The CDR and Specialized Registry provide a powerful platform to develop patient-centric processes that drive efficiency for the Bundled Payment program.
CDR Measurement Enhances Coordination Among Bundled Payment Providers
Bundled Payment programs necessitate enhanced communication and collaboration among providers. The CDR can measure whether these activities are occurring and the quality of the efforts. What might such measures look like? Here are a few possibilities:
- Measure whether all involved providers have given feedback on the causes of utilization variation and whether patient goals and expectations have been met;
- Measure whether feedback has been obtained on quality of care transitions and provider teamwork;
- Obtain patient feedback on efficiency and affordability of the care provided.
How the Specialized Registry Contributes to Bundled Payments
We’ve been focusing on how a CDR enables performance measurement for Bundled Payments. When configured as a Specialized Registry, it can also capture detailed data on specific patient populations for analysis and research, as well as for planning actions and interventions. Typically, such patient populations are built around disease conditions, but other Registry populations might be created. Registries might be based on procedures, geography or referral source, or composed to assess risks on intervention outcomes. The value of these Registries will increase with the addition of multiple data sources. For example, capturing remotely collected activity data from devices such as an Apple Watch or a Fitbit may reveal unexpected positive or negative effects from a particular intervention.
Specialists have much to gain from dissecting measures data and creating registries that reveal valuable comparisons. For example, a cardiologist should know which heart failure patients are excluded for functional assessment (Meaningful Use Measure 90v4) because of dementia or cancer. This cardiologist should also know what percentage of her heart failure patient population falls into this category, and how that compares to her colleagues’ outcomes. Recognizing that this population should be identified in the record increases the likelihood that the measure will be accurate. Additionally, this subset of heart failure patients should be considered for confirmation of care goals in order to meet the patient’s and family’s needs and wishes.
Specialists could also benefit from a personal registry of referring provider results. Understanding provider characteristics will help in creating and assessing provider-level interventions. A significant amount of such data already resides in practice management and EHR systems. Under both MIPS and APMs, specialty care physicians may find comprehensive Registry information on referral sources particularly relevant for understanding financial and quality levers of referring providers.
Multi-Specialty Clinical Data Registries Have Unique Benefits for Specialists
Specialty care physicians, in particular, must be engaged and nimble in achieving excellent performance, since they compete with others in their specialty. A multispecialty CDR offers the specialist the opportunity to work collegially with physicians in other specialties to measure and improve care.
Both the CDR and the Specialized Registry collect and analyze data for all patients regardless of payer. Providers ultimately must have uniform quality measures for all of their patients and not payer-specific measures—essential for reducing the complexity and duplication of performance measurement. In such a competitive milieu, it’s also essential for measure developers to create meaningful measures for specialists that lead to expanded patient input to accurately differentiate among specialists. Because the CDR also has the authority to develop measures, this customization to specialties is an advantage.
The Specialized Registry will track data and interventions, and serve as a platform for further CDR development. Analytics performed on the Specialized Registry may highlight variances that flag interventions to pursue for performance improvement within specialty groups that could not be undertaken without the benefit of CDR data.
For the specialty care physician, the CDR with its Specialized Registry components create a powerful mechanism for assessing different elements of his or her practice to avoid penalties and improve outcomes.
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Image Credit: Herman Brinkman