“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 Center’s 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 BPCI’s 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.
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