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Define the Episode
When does the episode start, and how long does it last?
Live birth identified through retrospective review of claims
Health plan / Payer notification during prenatal time period
- 270 days prior to delivery (so long as the woman was pregnant in this time period)
- First visit when pregnancy is confirmed
- 60 days postpartum for mom (most common) or other time period
- 30 days postpartum for baby (if baby is included) or other time period
How do payers and providers know which patient is being cared for under an episode-based payment?
- Include all patients
- Establish exclusions:
- High-risk pregnancies (which can be defined in many ways and negotiable, and identified after-the-fact for retrospective episodes).
Women who did not receive care from delivering provider during the prenatal time period.
- Women whose pregnancy was not confirmed until a pre-negotiated week of pregnancy (this includes women who did not seek services at the start of their pregnancy).
What services are included? Do those services cover care for the baby?
- All services inclusive of pregnancy or a smaller subset
- If baby is included in episode – consider whether NICU costs will be included, if they occur.
Setting the Patient Population – Thursday, May 4, 2017
Set the Episode Price/Budget
Establishing the Price/Budget:
What data is available?
Based on historical averages of:
- an individual physician
- a provider group
- ACO or IPA
- geography or marketplace
Based on expected services using payer rates:
- Calculated by identifying all expected services within an episode and using payer rates to build the episode.
Type of Risk:
Will the base price (budget) be adjusted for other factors?
Risk Adjustment Options
- Will the episode be risk-adjusted (and if so, how) OR will it be a flat rate?
- Will the payer offer a margin for providers (might be considered when provider efficiency is high)?
- Will the payer implement an underuse fee, whereby if certain services aren’t offered they will be automatically added to the price (budget) to prevent underuse of care?
- Will the payer offer stop-loss protection for outlier cases?
Level of Risk:
What risk model will be used with providers?
Identify the Risk Model
- Will the payer share any savings the provider generates? If so, what percentage?
- Will the payer expect the provider to share in any losses that are incurred? If so, what percentage?
- Will the provider be fully responsible for all losses and able to keep all savings it generates?
- Will the payer automatically take a percentage of the price as its built in savings?
Incorporate Quality Measures
Which measures will be utilized to measure quality?
Identify Relevant Quality Measures
- Identify areas for improvement based on current performance
- Engage providers and stakeholders in choosing measures
- Consider measures already collected, reported or publicly available, including those used by other payers
- Consider measures with state, regional or national benchmarks
How will the payer and provider determine performance?
Determine How to Reward Quality
- Performance relative to benchmarks or targets
- Performance relative to other providers
- Performance relative to past performance
How will performance on measures be tied to savings or risk?
Determine How Quality will Affect the Episode Financial Model
- Integrate quality directly into the financial model and allow for performance to adjust the savings (or loss) percentages
- Use quality performance independently of the financial model, and reward with a separate quality bonus pool or another mechanism.
Quality Measurement Part 1- Friday, March 3, 2017
How will the payer operationalize the episode-based payment?
- Fee-for-service with retrospective reconciliation to the episode budget.
- Prospectively paid at the start of the episode. (If this option is chosen, the trigger can’t be a live birth.)
When will reconciliation payments be made?
- With what frequency will the payer reconcile payments?
- Will the provider face penalties for claims not submitted in a timely manner?
- Will the payer face penalties for late reconciliation?
How will the payer distribute payments to the contracting entity?
- Depending on the contracting method, the payer needs to identify how payments will be distributed.
- Will accountable providers have any requirements to distribute shared savings payments to subcontractors (if applicable?)
How will data be used to assist providers in managing to an episode budget?
- What data should providers expect to get from payers to help them track costs relative to budget for each episode?
- How will the data be shared, (e.g., web portal) and with what frequency (e.g., monthly, near-real-time)?
Contract with Providers
Which providers are ready for a maternity episode-based payment?
- Identify providers amenable and have licensure to contracting for episodes
- Share data to engage providers
- Conduct readiness assessments
Which providers will have contractual obligations?
- Payer contracts with one principal accountable provider
- Payer contracts with one provider, which in turn subcontracts with other providers
- Payer contracts with each partnering provider
What details should be included in the maternity episode-based contract?
Create and Execute Contract
- Episode definitions (with specificity of billing codes)
- Terms of payment
- Appeals process
- Provider responsibility for reporting, frequency of claims submission
- Payer responsibility for data sharing