CCGroup supports all three (3) ways our clients desire to drive towards high-value care, stated Dr. Douglas G. Cave, President of CCGroup. One area of focus is bundles-of-care. The CMS Innovation Center introduced the Bundled Payments for Care Improvement (BPCI) initiative as a way to improve performance accountability when actually performing the bundle of interest “ and the current 48 bundles in BPCI are supported by CCGroup.
Dr. Cave continued, CCGroup BundleCare„¢ is designed to meet the CMS Innovation Centers criteria for building and analyzing bundles. These bundles include knee replacement, cardiac arrhythmia, congestive heart failure, chest pain, and spinal fusion.
Another CMS payment initiative, the Merit-based Incentive Payment System (MIPS), was introduced to tie physician payments to bundled quality and cost-efficient care. In 2019, MIPS has eight (8) cost measure bundles and will add eleven (11) cost measure bundles in 2020 “ and these 19 MIPS bundles are also supported by CCGroup.
CCGroup BundleCare„¢ allows the user to select from a variety of parameters and tables to build bundles, defined John Calvin, VP of Clinical Systems. For example, BPCI triggers a bundle start by a specific hospital admission. Therefore, CCGroup allows for an inpatient trigger. But, we also allow for a hospital outpatient trigger because knee replacements are increasingly performed in an outpatient setting. Another parameter centers around BPCIs assigned table of ˜exclusionary services from a specific bundle. Consequently, CCGroup has an ˜exclusionary services table capability. However, MIPS bundled payment from CMS requires an ˜inclusionary services table; a parameter is set for exclusion or inclusion services in formulating bundles.
Dr. Cave stated, The second area of focus is the need to understand how many unwarranted healthcare bundles are performed in treating a specific medical condition. Most of the BPCI and MIPS bundles are also CCGroup MedMarkers„¢ “ however, there are many more MedMarkers„¢ than BPCI and MIPS bundles. We determine the rate of excess bundles using MedMarkers„¢ and Clinical MedMarker Protocol Ranges„¢. We first define what these are, and then illustrate their importance to value-based care.
MedMarkers„¢ are the key services and procedures most associated with cost-of-care in treating a medical condition. For instance, MRI of spine is the main MedMarker„¢ (or correlated service) in treating non-complicated low back pain. CCGroup is the only company in the market that has developed MedMarkers„¢ for all prevalent medical conditions, Dr. Cave said.
Clinical MedMarker Protocol Ranges„¢ are achievable and clinically appropriate ranges of clinical practice for MedMarkers„¢. These ranges are developed and maintained by presenting the CCGroup National Comparative MedMarker Database„¢ results to the CCGroup National Specialist Panels. Specialists on a CCGroup National Specialist Panel define the percentage of patients where a MedMarker„¢ service is likely clinically warranted.
Physicians want to understand how many unwarranted bundles [or MedMarkers„¢] are performed in treating specific medical conditions. The medical condition-specific MedMarkers„¢ and Clinical MedMarker Protocol Ranges„¢ address this need, mentioned Mr. Calvin.
The third area of focus is the need to improve performance accountability before performing the bundle of interest. We develop with our clients ˜Quantitative Clinical Pathways (QCPs) to ensure that only appropriate services are performed before a bundle service is performed, stated Dr. Cave.
QCPs set appropriate, quantified standards of care before a specific bundle is performed. For example, MRI of joint extremities is often performed 30 days before a scheduled knee replacement. Dr. Cave continued, The question is why, because orthopedists generally know the patient has osteoarthritis as the attributable factor for the upcoming knee replacement. Therefore, MRI of joint extremities should undergo medical policy review to determine its value 30 days before a knee replacement.
About Cave Consulting Group (CCGroup)
Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 28 years for health systems, health plans, HMOs, physician groups, TPAs, and employers.