Implementing Bundled Payments in Wisconsin: Lessons from the Field
Karen Timberlake, director of the Partnership for Healthcare Payment Reform (PHPR) in Wisconsin, describes lessons learned during bundled payment experiments in 2012.
Bundled payment for total knee replacement in the commercially insured population is up and running in three locations in Wisconsin. These organizations, along with three payer partners, are participating through the Wisconsin Partnership for Healthcare Payment Reform, a project of the Wisconsin Health Information Organization. These first three participants were featured at our June Summit (link back to Helen's post which includes their presentations). They have been down the road long enough to have some insights to share. Here are a few of their key takeaways from 2012:
Overall Keys to Success:
• Senior leader support. In all three organizations, senior leaders have made their commitment to the bundled payment project known, have deployed staff with the right skills to drive the project forward, have made resources available, and have helped the project survive and thrive in the midst of many competing priorities.
• Engaging physician leaders. Reaching out to physicians who are identified leaders within their organizations has provided critical clinical perspectives to the TKR project and created clinical champions to drive the project forward. While some physicians initially expressed concern about taking responsibility for costs that are outside of their control, these issues are vetted through open communication and regular, frequent data sharing.
• Trust, relationships, and attitude. In each case, providers and payers built upon historical trust relationships to overcome implementation obstacles. Payers, in particular, were credited by providers with taking a positive, proactive approach, backing up their expressed desire to move the project forward with flexible approaches to data sharing and contract provisions. In one case, the provider and payer reduced the terms of the bundled payment agreement to a three page contract addendum.
Working With the Data:
• Link questionable claims by date. While it can be difficult to attribute claims in the post-surgical period to the bundled procedure, participants had success by linking questionable claims with the same date of service as claims that were clearly attributable to the TKR procedure. This approach avoided the temptation to let "perfect" be the enemy of "progress."
• Engage patients early. Participants have focused on engaging patients in their own care, rather than engaging them in the details of the payment model. Participation in the payment experiment has caused providers to redouble their efforts to engage patients before the TKR procedure, in some cases months before, as well as after, in taking good care of themselves to support the best possible outcomes.
Driving Quality Improvement
• Share data. All participants have found that the payment reform project has supported a sharper focus on clinical redesign. Physicians are asking for their data and are sharing their ideas for how to improve.
• Focus within the continuum of care. Providers are initiating targeted process improvement conversations to drill further into the opportunities to improve various aspects of patient care (e.g., use of outpatient rehab vs. skilled nursing facilities). Payment reform promotes new awareness of opportunities to improve, which prompts new activities in support of the desired improvements.
• For payers and providers alike, identifying patients for the bundled payment project, and handling those claims manually, remains a major impediment to expanding bundled payments. It isn't clear to most participants how to make the leap from small pilot projects to full-scale approaches to bundled payments for all appropriate conditions.