Pricing #7: Additional Contracting Considerations - Care Pathways

One way payers can encourage providers to participate in a bundled payment program is by clearly identifying how that particular provider can succeed. Aver typically starts its customer engagements by analyzing the most recent two years of a customer’s claims data, helping payers and providers identify efficient care pathways and how to make those pathways part of their standard operating procedure.

By reviewing historical performance, Aver can help providers see that episodes involving a particular type of post-acute care or a particular post-acute care provider tend to cost less while quality remains uncompromised. On the other hand, by reviewing higher-cost episodes, Aver can help identify potentially inefficient providers whose involvement in the bundle tends to raise the overall cost of care. This analysis can help providers identify efficient partners with whom they might enter into downstream agreements for care provided to patients involved in the bundled payment program.

Aver’s analysis of historical claims data can also help providers identify inefficient care pathways and pinpoint efficient care pathways, helping providers develop standards that result in high quality, low-cost care for their patients. With the development of these care standards, many providers hire care coordinators to track and manage the standard care pathways. Providers who use care coordinators often have them make follow-up calls to patients at regular intervals following a procedure. During these calls, the care coordinator can ask questions about incision site healing, pain levels, or mobility, and gather other types of information to assess the patient’s general status. Patients whose recovery is not proceeding in a typical way can meet with a provider as soon as possible, taking care of problems before they worsen and avoiding leakage claims.

I briefly mentioned leakage claims in a previous post. A bundle definition identifies health care services that are relevant to the episode of care and included in the bundle. Some of these relevant services may be performed by a provider who participates with a patient’s insurer but is outside of the bundle contract. For example, consider a patient experiencing pain three days after undergoing a procedure as part of a bundled payment program. Rather than contact the episode initiating provider who performed their procedure, they seek care at an emergency room or urgent care center that is part of their insurance network. The insurer pays these claims on a fee-for-service basis and because they are considered relevant to the episode, they are included in the total episode cost.

Because these leakage claims can have a dramatic impact on total episode cost, episode initiating providers must consider how to communicate with and involve patients in order to better manage leakage. I highly recommend that providers participating in a bundled payment program ensure that patients understand the program. Some providers may ask a patient to sign an agreement verifying their understanding and confirming that they have a caregiver for the immediate post-procedure period and will call the episode initiating provider with any questions or concerns before pursuing other types of care.

Aver helps payers work with providers to establish efficient care pathways before enrollment of the first patient in a bundle program. If a provider intends to use a care coordinator, that person will ideally be hired and onboarded before the contract begins. Many providers who participate in Medicare bundled payment programs, such as Bundled Payments for Care Improvement or Comprehensive Care for Joint Replacement, have already invested in care coordination. These care coordinators are critical to a provider’s success in Medicare bundles, but depending on patient volume and payer mix, providers may have excess care coordination capacity. In this case, providers may be interested in pursuing bundles with commercial and other payers to better utilize care coordinators and enhance revenue.

Providers generally do not have insight into the kind of information Aver is able to share from careful analysis of claims data. When a payer does not share utilization data with a provider, that provider may only be aware of care provided to a patient within their four walls. At best, if they are part of a health system, they may see care provided within the system. By seeing the complete picture of their patients’ care pathways, providers can understand the complete picture from a total cost of care perspective and can partner with payers to use efficient care pathways that reduce cost while maintaining or improving quality.

Elaine Daniels Aver

Director of Network Strategy
Aver, Inc

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