We sat down with Lesli Ott, Director of Episode Development for Remedy Partners’ Payer and Provider Solutions Group. Lesli leads a team of top analysts who collaborate with Remedy Partners’ clinical, technology and business teams to design and implement effective bundled payment programs for payers and providers. Here’s what she had to say about how payers and providers are driving better care and cost outcomes by implementing bundled payment strategies:
How do you do work with private payers, and what problems do you help them solve?
We partner with payers and their network of providers to identify and solve inefficiencies related to healthcare delivery on behalf of their members. Improving the patient experience is always our primary goal. We specialize in building episode-based frameworks to tackle the healthcare challenges unique to each payer’s population. More specifically, an episode-based framework is one that captures, for a defined period of time, all care administered by all providers for treatment related to a patient’s medical condition or procedure.
How do you identify inefficiencies that are preventing payers from delivering better healthcare to their members?
We analyze several years of a payer’s member-level data to understand which care patterns lead to the best outcomes for their members and which care patterns can be improved. We also identify care for which there is unexpected variation in cost across providers. We then use external payer datasets for a similar member cohort and geographic region to provide both care utilization and quality benchmarks. This combination of internal and comparative analytics allows a payer to quickly identify areas for improvement.
Do payers have different episode definitions? If so, why?
Yes, payers may have different episode definitions. This is because payers have different member profiles, provider arrangements and strategic initiatives. In order to identify the best episode definitions for a particular payer, we take the time to understand all aspects of a payer’s member cohort and business model.
What are the key challenges in establishing episode definitions for a commercial bundled payment program?
Often our biggest challenge is helping a payer understand how bundled payments work and how a program can benefit them and their members. Many payers are new to bundles and, though they may have heard of Medicare’s Bundled Payment for Care Improvement initiative, or BPCI, many aren’t as informed about bundles as they would like to be. Once we help them to bridge that gap, things tend to fall in place. They know they need help transitioning toward value-based care, but they don’t always know how bundled payments can play a significant role in that transition, nor how bundled payments can work with other value-based care or population health initiatives.
Much of the literature about Medicare bundled payments explains that the opportunity is focused on changing post-acute care patterns. Is the same true with commercial payers?
The size of the opportunity depends on the commercial line of business. For Medicare Advantage members, we often do see room for improvement in the post-acute care setting. For employer-based and Medicaid members, who are younger and typically have episodes that do not or should not necessarily begin in acute-care facilities, we see additional types of opportunity. For example, we see opportunity in shifting the site of care from inpatient to outpatient facilities, improving practices related to maternity care, better upstream management of chronic conditions and focusing on potentially avoidable care complications.
We’ve mostly been talking about payers, but do you also work with providers who are interested in approaching a payer about contracting under a bundled payment arrangement?
Yes, as more providers discover the benefits bundled payments provide to both their patients and their own practice, they are partnering with us to design a bundled payment program, get payers on board and implement best practices for success.
Explain your work for the Yale Center for Outcomes Research & Evaluation (CORE) and the key insights you learned there about episode-based measurement frameworks.
I was a lead statistician at Yale CORE and spent over six years developing episode-based cost measures and quality outcome measures for CMS. I learned several key insights from my work but will share two of the most important. First, currently there is not a strong enough correlation between cost and quality in healthcare. Thus, there is a lot of room to reduce healthcare costs while maintaining and even improving healthcare quality. Second, episode-based cost measures are the best way to incentivize optimal cost and quality outcomes, because they reflect the patient’s experience within the healthcare system by capturing all related care for a given condition or procedure over a specific timeframe. In doing so, they promote better coordination across the care continuum which, in turn, helps to reduce the inefficiencies that lead to high costs and poor quality.
What led you to join Remedy Partners?While I enjoyed and appreciated academic work, I joined Remedy Partners for the opportunity to help generate analytic insights which are put directly into practice at the patient-level. Remedy Partners not only identifies best practices that lead to improvements in healthcare cost and quality but also partners with payers and providers to effect positive change in real-time patient care. Because I care deeply about making a difference for people during very vulnerable moments in life when they most need healthcare, it was an opportunity I could not pass up.