4 risk adjustment opportunities to make bundled payments sustainable


As hospitals move into value-based care and alternative payment models, such as bundled payments, they need to reconsider the role of the emergency department and unscheduled care.

Once a revenue generator, the ED is now a cost center. Once the front door to the hospital, efforts are being made to meet patients in the community and avoid the ED altogether. Perhaps most importantly, the ED was once an isolated decision making unit, but now it is essential to integrate decisions made in the ED with those being made throughout the care continuum, particularly those related to patients in bundles.

"Emergency department utilization ebbs and flows throughout a bundle," Susan Nedza, MD, senior vice president of clinical outcomes management for MPA Healthcare Solutions, said during a webinar hosted by Becker's Hospital Review. Her presentation highlighted four specific domains where providers in bundled payment programs have the opportunity to better anticipate patient needs. "Each of these points provides a healthcare system an opportunity to reassess the risk for these patients."

Here are those four domains.

1. Pre-procedure utilization.
Pre-procedure utilization is often overlooked, but Dr. Nedza advises providers to focus in on this time period because it can help establish a sense of the risk they will need to manage in each case. The time period can vary depending on the bundle, but it typically encompasses the 30 days prior to the procedure.

"When we the look at the pre-procedure utilization in the ED, what we are focused on is recognizing chronic conditions that require management and may impact the patient's care." Pre-procedural clinical and financial risk factors to watch include the utilization rate, diagnosis for ED visits, conditions likely to be destabilized due to a certain procedure and patient demographics. The key collaborators during this stage of the bundle will be primary care and emergency medicine physicians.

2. Immediate post-procedure discharge. 
The week after a patient's discharge represents another opportunity for providers to manage risk. For some patients, the discharge is the last encounter they have with the care system. However, the unscheduled care that does occur can be improved through enhanced discharge planning and management of patient decision-making.

Dr. Nedza advises providers to consider the clinical and medical liability risk associated with discharge. Is the timing appropriate based on a patient's comorbidities and complications? How likely is it they will visit an ED? Who is making the discharge decision? "If it's the orthopedic surgeon, or their PA or APRN, they may be looking at the orthopedic condition, but may or may not have real insight into other conditions that are likely to be destabilized and the likelihood of an ED visit," she said.

She also advised providers to consider patient-specific details that could affect early decompensation, such as the distance a patient lives from a joint center. "This is where the care navigators come in and not only explain to patients that it may not be appropriate to go to the ED first, but also provide input to maintain [patient] connectivity to your system when they do need unscheduled care."

3. Within 30 days of discharge.
If patients visit the ED within 30 days of their discharge from the procedure, they face new types of risks. At this point, patients have been in their homes or in a skilled nursing facility and may have been exposed to bacteria or may have fallen in their home. Many ED visits at this time are still related to the procedure, though they require time to develop — such as urinary tract infections or constipation due to painkillers. "It's not always correlated with the risk they had prior to surgery, or at the time of discharge," Dr. Nedza said.

At this step in the bundle, providers should identify and focus procedure-specific visits to the ED and develop protocols for efficient, effective management of those visits. According to Dr. Nedza, providers need to shift how they view discharge dispositions during this time period. Emergency physicians tend to look at post-procedural patients who come to the ED within 30 days of discharge and evaluate if they meet hospital admission criteria. "That's not the appropriate question to be asking. It makes sense from a payment perspective, but as a physician, I need to look at this as what is the likelihood of an adverse outcome if I discharge this patient?" she said. "The reality is most patients want to go home, but at times there is a risk associated with that discharge."

4. Within 90 days of discharge.
The final opportunity to improve ED integration comes within 90 days of discharge. The intervention strategy Dr. Nedza recommends here is to enhance focus on managing chronic diseases, particularly as they may have been impacted by the procedure.

"There is an intrinsic pattern of utilization for patients related to either chronic conditions [patients] have that occur prior to their surgery and if they are seen in an ED in the post-discharge period as we go out to 90 days… there is continued utilization. Some have returned to baseline, but when we look at the diagnoses they are a bit different," Dr. Nedza said.

For example, neuropsychological issues, particularly for elderly patients, are often overlooked, according to Dr. Nedza. However, anesthesia disrupts elderly patients and may exacerbate existing issues or cause them to return to the ED due to altered mental states or paranoia associated with pain medications.

"When we look at potentially risk adjusting or re-evaluating risk for these patients, we need to do it multiple times during the post-discharge period," she said. This is because many unscheduled ED visits up to 90 days out "may not have been predicted at the time they were admitted to the hospital, but may have been impacted by events during the post-discharge period."

How to get started
The first thing providers can do is review their ED data, especially their pre-procedure ED data. "There's a lot of value there," Dr. Nedza said. This will enable hospitals to proactively identify potential cost savings related to unscheduled care and identify opportunities to include and partner with ED providers in managing the risk. She also recommends hospitals use precision risk-management tools to stratify risk across the bundle. Lastly, she says hospitals must monitor performance to track the efficiency and effectiveness of their interventions.

The goal is sustainability, according to Dr. Nedza, and any efforts made to improve integration and manage unscheduled care will pay off in many different ways. She said providers can expect to see benefits in terms of increased ED capacity, reduced post-discharge leakage and more appropriate use of alternative sites of care.


For more information, watch the full presentation here. Download the slides here.

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