Bundled Payments in a Time of Uncertainty

AMI, CABG, and SHFFT EPMs and Commercial Bundles

Rocky Edmondson, RN, BSN, MBA, CCRN, Senior Director, Bundled Payments, Care Redesign & Management Advisors, xG Health Solutions, March 10, 2017

Each day when we turn on the news we are confronted with the terms “repeal and replace”, referencing the Affordable Care Act (ACA) and a direct implication for those utilizing the insurance exchange. As recent as Monday (3/6) the Republican controlled House of Representatives, led by Paul Ryan, introduced the American Healthcare Act, with the intent to repeal and replace the ACA. However, it would appear that the bill in its current form faces significant headwinds, which could delay or prevent it from becoming law. And while the ACA has been the catalyst for the movement in care delivery models from fee-for-service to value-based care, of which bundled payments are a key element, uncertainty still persists. So what does this mean for bundled payments going forward?

We recently had the opportunity to present and interact at several meetings and conferences, which had some of the brightest healthcare minds in attendance. Here is what we observed:

Improving care and reducing cost. Once you cut through the noise surrounding the “repeal and replacement” of the ACA, the fact remains that bundled payments have proven to improve quality and reduce cost. Additionally, bundled payments have enjoyed wide bipartisan support. However, with the confirmation of Dr. Tom Price to head the Centers for Medicare and Medicaid Services (CMS), the future of mandatory bundled payment programs remains in flux, especially the AMI/CABG and SHFFT episode payment models (EPMs). Many healthcare organizations I spoke with are moving forward with evaluating their current care in these areas utilizing data analytics, and establishing a plan to succeed under these EPMs. They are moving forward with the assumption that these EPMs will be implemented at some point, and if not, they will at least be well on their way to improving care and reducing costs for this population of patients.

Commercial bundles – Improving revenues and maintaining market share. As noted in previous blogs, many private payers are turning to bundled payments as a means to improve quality and outcomes, while reducing costs. As a result, healthcare organizations are starting to see the potential of commercial bundles in improving revenues, and maintaining market share, while displaying improved quality and outcomes within their organizations. These providers are eager to be the first to market with a commercial bundled payment product, therefore generating interest from payers and employers. The idea is that by providing bundled payment programs to payers and employers, the organization will become the preferred treatment site for the patients represented by employers and payers.

Whether it be episode payment models from CMS or commercial bundles, these are complex undertakings for most healthcare organizations. It’s important to note that the final EPM rules from CMS were 1,759 pages and covered many topics. The ability to succeed in commercial bundles, or the new EPMs from CMS, is dependent on proper preparation and the understanding of the nuances of these programs, including: data analytics, program development, implementation, and risk management.

Are you prepared to succeed in these and other value-based programs? Are you interested in learning how to be successful in bundled payments? If so, please feel free to contact Andrew Blackmon at ablackmon@xghealth.com


Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

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Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.