1. Cost and Performance Management Under Alternative Payment Models
What are the roles, responsibilities, skills, knowledge and personal attributes of a successful physician leader in a fee for service environment?
FFS = V x P
What are the roles, responsibilities, skills, knowledge and personal attributes of a successful physician leader in an alternative or value based payment environment?
V = Q / C

2. How Bundled Payments Work

3. Bundled Payment for an Episode of Care

4. Components of Episode Pricing
All hospital services (Medicare part A) provided during stay are included
Patient inclusion criteria must be explicitly defined in advance
Physician services (Medicare part B) for
Surgeon
Anesthesiologist
Cardiologist
Radiologist
Consults
Bundle period is defined as 30, 60, or 90 days
Days of inclusion:
Pre op day, (all preadmission lab work completed prior to admission)
In Hospital Stay (number of days based on historical and current practices)
Post op follow up, SNF, Rehab Facility, NH, Home Health Care

5. Bundle Based Payment for Episode of Care
Bundle of Care Model
Fee for Service Model
All Physician Services; billed
separately, inpt and outpt;
Include PCP, Specialist;
Surgeon; Radiologist, etc.
All physician services, pre-admit, inpt, and post discharge.
Governance Model
and method agreed
to distribute payments
to all physicians,
in-patient
facilities, hospitals,
SNF’s, etc. and all
care givers involved
in the bundle. Need
for metrics,
transparency,
adjudication of
disputes, and stop
loss provisions.
Separate FFS
Physician
Payments
Single
Contracted
Payment for
all Physician,
Hospital and
Follow
Up Charges
All hospital services,
Including staff, pharmacy and technical component of radiology and lab. Also ED and readmit.
Include all inpatient charges,
and any ED or Readmit
Charges
Hospital Charges Paid
Post Discharge
Follow Charges
Paid
All follow up rehab, SNF, NH, Home health and PT
Include all Rehab, SNF, NH
and PT Charges, either in
facility or at home

6. How Population Health Works

7. Difference Between a FFS & a Population Health Panel
The Sickest Patients
Patients with Medical Conditions – “At Risk”
In an average non-Medicare population, there is a large number of “healthy patients”
In a Population Health Panel, payment or capitation is for the entire panel of patients.
In FFS Panel, payment is per unit of service, only for those
patients seen in the office or hospital.

8. The Entire Population Health Portfolio is Required
Access
Extended hours. Teams. Asynchronous care. Partnering, e.g. retail clinics. Self management. Apps.
Patient-Centered Medical Homes
Physician directed teams. EMR. Coordination with specialists. Service. Disparities.
Care Coordination
Care coordination. Health Coaching. Care management. Social work. Clinical pharmacist. Care navigation.
Data Analytics/Reporting
Connectivity.
Aggregation.
Analytics.
Risk stratification.
Dashboards and reporting.
Evidence-based Medicine
Guidelines/protocols that are created and agreed to by the providers.
Wellness and Prevention
Technology-apps, portals. Coaching. Automated outreach. Benefits design. Community/govt engagement. “Contemporary nutrition”, eg GMO, pescatarian, vegan.
PCMH
Does current payer care coordination, case management work?

9. 1 2 3 4 5 Risk Stratification Analytics DEFINE ASSESS STRATIFY ENGAGE
MANAGE
Population Identification
Health Assessment
Risk Stratification
Enrollment / Engagement Strategies
Management / Interventions
Tailored Interventions —
Care Coordination
Disease / Case Management
Health Risk Management
Health Promotion / Wellness
Meeting patients where they are
…physically
home | school | work | shopping | in the clinic
…in the way that works best for them
| text | internet | phone | video | face-to-face

10. Financial Model for Taking Risk for a Population