Patient Engagement Tool Helps Providers Optimize Bundled Payment Outcomes

Since 2013, CMS has been experimenting with a variety of payment mechanisms in order to determine if payment methodology can promote better and less expensive medical care. CMS originally allowed voluntary participation, but that approach changed with two dramatically different but expensive classes of common medical interventions, cardiac and orthopedics. The orthopedic bundled payment rules were finalized in November 2015 and represented the first time CMS mandated participation (starting in mid 2106).

The new bundled payment models for cardiac care include coronary artery bypass grafts, acute myocardial infraction (MI), and percutaneous coronary intervention are mandated for at least some hospitals starting July 1, 2107. A specific component of the cardiac bundled payment program is the focus on cardiac rehabilitation. The final rule for the cardiac bundles and changes to the Comprehensive Care for Joint Replacement model (CJR) was released on December 20, 2016.

For orthopedics, the care includes elective total joint replacement of hip and knee joints as well as hip fractures. Given that the CMS regulations would take at least three reams of paper to print, the requirements are, to say the least, extensive. Basically, CMS feels that if all payment for the episode of care (which encompasses a 90-day period after discharge) is bundled into one payment, then various stakeholders in the care will be forced to work together to better coordinate care and prevent adverse events.

CMS, as is norm for demonstration projects, is using both positive (termed gainshare) and negative (termed discounts) incentives for the payment. For example, 10 quality measures are used to create a composite score to earn back increases in target price. Minimum quality thresholds must be met for gain share. CMS has also included waivers in both CJR and the newly announced bundles that waive restrictions for telehealth and the Stark law to encourage the use of patient engagement technology and services.

Obviously, government mandated bundled payment models require enormous changes to our medical delivery system. The rules, although voluminous basically require that hospitals, physicians, and ancillary care delivery service providers become much more proactive in all phases of care for the respective conditions. These requirements have not gone un-noticed by innovative companies; one of which is a small company called HealthLoop.

HealthLoop is located in silicon valley with about 40 employees and was founded in 2010 by physician Jordan Shlain MD. The company provides an automated patient engagement tool that can communicate with patients and at the same time collect data.  Its aim is to provide timely interventions in order to change behavior and predict potential complications in time to have a care manager intervene. Their platform does this by sending scheduled email check-ins that deliver timely condition-specific and empathetic guidance, reminders, clinical questions, and educational materials. Their system also asks questions pertinent to the phase of care. For instance, it asks if patients about to undergo a knee replacement have prepared their home a few days prior to their actual surgical date. 

These messages continue until the episode of care is over; something that varies by type of care. The messages look like they have come directly from their physician or a hospital system and the answers are automatically screened for exceptions so as to alert a case manager to intervene. They have over 140 different conditions embedded within their platform and most recently have focused specifically on helping hospitals meet the demand of the CMS’s revised CJR and cardiac care program.

For a CJR episode of care, they start the interaction about 30 days prior to surgery and have numerous interactions in this time period. Their questions ask if the patient has prepared the house, if the patient has a rash or skin lesion near the surgical site, and if they have any questions. Immediately after surgery, the messages start with questions about early signs of any potential adverse event such as a deep vein thrombosis (DVT) as well as pain control, and prescribed exercises. Messages have customizable features to allow each physician to have his own preferences imbedded into the interaction.

As an example of their scalability, last month they recorded over 450,000 interactions involving nearly 60,000 specific check-ins by their participants monthly. Patients can see a running record of the dialog along with other information that can be imported into EPIC EMR as well as My Chart.

HealthLoop has discovered that engaging with patients can lead to fewer readmissions as well as better overall outcome. And, of interest, their most common age group is age 61 to 70—demonstrating the technical prowess of the seniors! They have over 50 clients, most of whom are hospitals. They charge a flat fee for each episode of care per patient; prices range based on volume, service lines and level of integration dropping with volume and increase in the number of specific conditions.

HealthLoop is another of many examples of how innovative software companies are rapidly responding to CMS and other market forces in our quest for a better medical delivery system.