Becker's Hospital Review

122 Executive Briefing models, including prospective bundle contracts. "Most healthcare organizations know their cost of services, but they don't have the capabilities to model risk in prospective bundle contracts," Mr. Adams said. "This requires access to facility and physician claims data and developing algorithms to model risk for episodes of care." Accurately assessing risk is critical for health systems and other medical facilities entering direct contracting arrangements. "If you get the pricing wrong in these agreements, it can be a big miss, and the program will not be sustainable," Mr. Adams said. To help ensure success under direct-to-employer contracts, hospitals and other provider organizations across the nation are using Global Healthcare Alliance's bundling adjudication software platform, Axia, which converts fee-for-service transaction data into contracted bundled package pricing and reimbursement models. Global Healthcare Alliance uses large databases and proprietary algorithms to help healthcare organizations determine the feasibility of direct contracting arrangements in particular markets. The company works with systems to develop a portfolio of bundled episodes and then markets it to employers. Global Healthcare Alliance can also provide healthcare organizations and employers with insights to help them take on certain services typically provided by an insurer. For example, when entering a direct contracting agreement, the health system and employer need transparency into cost data and other information to negotiate a fair and sustainable reimbursement rate for the bundles, according to Mr. Adams. "By that, I mean it covers the amount of risk the provider assumes in the episodes of care, and it provides value to the employer based on: high-quality outcomes, reasonable utilization rates, right care at the right time, predictable costs, and employee and patient satisfaction," he said. To participate in direct contracting arrangements, hospitals and health systems also need the capability to process complex claims such as bundled payments, which typically require additional data management and review to ensure proper reimbursement compared to traditional claims. Global Healthcare Alliance's platform can process these claims without disrupting the revenue cycle. In addition to the right technology, health systems that contract directly with employers must also focus on improving the patient experience. "From a day-to-day operations standpoint, engaging with the patient and helping them with registration and navigation through the process is critical," Mr. Adams said. "They expect concierge services in these COE programs." CardioVascular Care Providers achieves success with direct- to-employer agreement Since 2000, Global Healthcare Alliance has managed a direct contracting agreement between a multinational energy company based in Houston and CardioVascular Care Providers, a network of cardiovascular physicians in Houston — and the program has achieved impressive results. The center of excellence program includes a portfolio of outpatient and inpatient bundles covering everything from an office visit and diagnostic testing to heart transplants, according to Mr. Adams. The energy company incentivizes its employees to use CardioVascular Care Providers by paying 100 percent of the coinsurance and patient portion. For example, the energy company pays the patient portion and coinsurance if an employee uses a CardioVascular Care Providers physician and receives care at CHI St. Luke's Hospital in Houston. Many direct contracting arrangements involve a national payer with a limited role, as is the case with the CardioVascular Care Providers program. "The cardiovascular component has been carved out and is administered by Global Healthcare Alliance," Mr. Adams said. "The insurance company basically provides patient rosters for eligibility purposes." The energy company has achieved cost savings for the 16,000- plus employees enrolled in the program and has improved the quality of cardiovascular care its employees' receive. Moreover, the energy company has achieved cost savings of more than 30 percent for all employees enrolled who were admitted for coronary bypass grafts. The company has achieved cost savings of 10 percent to 20 percent for all PCIs. The program has a zero percent mortality rate, and none of the employees who received a coronary artery bypass graft required a re-do within a year of the initial surgery, according to Mr. Adams. Conclusion Employers nationwide are taking strides to reduce healthcare spending, and many are contracting directly with hospitals, health systems and other medical facilities to achieve this goal. As the industry transitions away from fee-for-service medicine and toward value-based care models, these direct deals can be beneficial for the employer, employees and the healthcare organizations involved. Direct contracting arrangements can help employers achieve healthcare savings, improve health outcomes for employees and offer hospitals and health systems an opportunity to increase revenue by providing high-quality care to a set patient population. "Unless insurance companies are willing to invest in their systems to accommodate these new bundled models, we are going to see more and more direct contracting," Mr. Adams said. n Global Healthcare Alliance (GHA) is based in Houston, TX, and is a pioneer in delivering value-based reimburse- ment solutions, with more than 30 years' experience designing, building, and managing prospective bundled payment arrangements that are economically sustainable and steeped in clinical excellence. Founded by physicians, GHA serves as a powerful connector between patients, providers, payers, and employers. GHA provides a comprehensive suite of services, including advanced analytics, operational capabilities, and tech- nology solutions, that directly address the data, systems, and processes necessary for healthcare organizations to not only transition to value-based care, but to prosper long term. Today, GHA serves its more than 1,000 providers through a variety of value-based strategies including payer-contracted models, as well as, employer-sponsored centers of excellence and destination care programs, all demonstrating Quality, Care and Value. Together.

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