RCS-1 Reimbursement Crosswalk Model
HealthPRO®/Heritage has developed a proprietary, sophisticated RCS-1 Reimbursement Crosswalk Model that will help us work strategically with partners to assess aggregate reimbursement risk and understand the interplay between nursing and therapy reimbursement components. The model is dynamic, allowing behavior changes to be modeled so providers can see the impact of specific elements that significantly drive reimbursement under RCS-1 (e.g.: such as diagnostic coding, cognitive assessment, and ADL scoring).
Welcome to the HealthPRO Heritage Blog
Posted on: September 26, 2017
Posted on: April 11, 2016
The Time is Now to Execute on Initiatives to Optimize Patient Care & Demonstrate Positive Outcomes
Accountable Care Organization (ACO) networks and bundled payment programs continue to gain momentum across the nation. As such, these influential networks (inclusive of physician groups, hospital systems, managed care, etc.) are becoming more influential and even more refined.
Every post-acute care (PAC) provider must be considering strategies to link elbows with referral sources, ACO/bundled payment networks, managed care networks and regional conveners. After all, the climate has changed quickly and dramatically; consider the startling statistics:
- Currently, one in ten Medicare beneficiaries are attributed to an ACO
- 50% of all payments this year will be via a value-based program
- 90% of FFS MCA dollars are linked to quality or value
The impact of these health care reform mandates speak volumes! They suggest that this shift will continue to gain momentum. For example, several studies demonstrate the percentage of bundled payment patients discharged from the hospital setting directly to a skilled nursing facility has dropped as much as 30% - 50% for orthopedic and cardiac valve replacement surgeries.
Becoming part of a preferred network or bundled payment program is critical to PAC providers’ survival, but it comes with a price: high expectations!
Healthcare organizations and networks are seeking only strategic partnerships that will help them to remain financially viable. As such, it is imperative for PAC operators to not only understand these expectations, but to also execute on processes, programs and plans in support of these important strategic changes as soon as possible. The following discussion encourages swift and smart execution on three critical drivers: quality patient care, monitored performance metrics and tactical operational changes.
Patient Care is Paramount
CMS’s focus on the “Triple Aim” initiative dictates whether many PAC facilities will survive the healthcare reform transition. There is a universal sense of urgency related to adopting internal care designs to improve quality patient care and satisfaction; improve the health of populations; and to reduce the per capita cost of health care. Additionally, the “Six Aims for Improvement” defines “ideal healthcare delivery,” and PAC providers must also be prepared to demonstrate their efforts to align with each of the six quality indicators, which state that care should always be:
- Efficient Equitable
The Power of Performance Data
The key to unlocking strategic partnerships is the ability to demonstrate positive performance data. In fact, ACO networks and those who own bundled payment programs will require preferred PAC providers to report out on bi-weekly/monthly/quarterly reports on performance metrics and key outcome measures to designated Clinical Care Coordinators. At the minimum, a PAC operator should have systems in place to swiftly and easily demonstrate:
- Functional outcome measures
- Care coordination measures
- Patient engagement measures
- Organizational capability measures
- Composite measures
- Efficiency measures
- Disparity measures
- Performance Measures
- Re-hospitalization rates by diagnosis;
- Percent of patients discharged home/ with home care / with out-patient referrals
- Average length of stay by diagnosis for both SNF & HH partner
- Quality Measures- sepsis/UTI, falls, cognition, etc.
- 5-Star Ratings
- Therapy intensity (minutes/week)
- Functional Status Changes/LOS
- Control group/peer benchmarking/ hospital & national standards
- Cost/episode by diagnostic group
PAC providers can also leverage the power of performance data related to marketplace intelligence and data analytics specific to their referral sources. For example, it’s important to understand how a referring hospital’s reimbursement and their cost is associated with readmissions, VBP adjustments and/or Avoidable Hospital Days. Consider the value of a savvy PAC operator who is able to identify and strategically execute on interventions that contribute to the mitigation of unnecessary costs for their referral source; a “Win-Win” result in this scenario would surely hard-wire an important network partnership.Read More