Episode of Care Strategy that covers Physician Risk succeeds where procedure “Bundles” Fail"

Episode of Care Strategy that covers Physician Risk succeeds where procedure “bundles” fail.

Surgical “bundle” offerings from claim aggregators have focused on price to attract self-insured employers, who justifiably seek to control and make predictable their healthcare costs. It’s a compelling concept for employers – enabling employees to choose a lower cost alternative for their surgery by offering a tier one service choice with reduced or eliminated deductible. Physician groups are intrigued by the prospect of fewer barriers to their care recommendations and faster payment.

However, while it’s been beneficial to stakeholders in some cases, the approach has had significant challenges.

• Constructing “bundles” has taken considerable effort for physician practices, with no guarantee of inbound cases
• Employees and employers have not been informed and engaged at the right stage to present lower cost options
• Patients and HR departments have evaluated multiple bundle proposals for a given case – with little insight into quality considerations
• Inadequate pre procedure care management results in complications and additional cost to employer, employee or physician
• Unforeseen complications in surgery create stakeholder conflict

Kate Grohall, MSOLQ Vice President of Value Based Solutions at Holista Health began her story during years of experience in orthopedic practices including the Orthopedic Hospital of Wisconsin. Kate was a key contributor in CMS’s effort to control high-cost joint replacement surgeries through their BPCI and CJR programs instituted in the 2010’s. However, Kate saw opportunity in the employer community not served by Medicare programs.

Kate’s vision was to create “episodes of care”. Not driven by price but by quality, predictability and risk reduction methodologies for all stakeholders.

• Holista’s episodes of care are honed by experience and constructed for practices who agree to follow their design rather than building them from scratch
• Working with innovative brokers Holista’s EOC’s are presented as tier one options integrated with the employer’s health plan and presented to patients by physicians empowered to choose Holista’s network of centers of excellence
• Consistent quality and guaranteed values lead to less complicated decisions for employees
• Extensive pre and post patient care management contribute to superior outcomes and lowered complication risk for all stakeholders
• Guaranteed pricing of episodes eliminates risk of additional cost to employers, patients and physicians

The focus on quality led Kate’s team to build extensive patient outreach – case management – into episode construction based on the successes of the highest performing caregivers. Unlike many insurance scenarios including the Medicare programs, non-compliant patients in “self-insured” employer plans are given financial incentives to choose a Holista center of excellence, incentives which are at risk if they don’t adhere to physician orders.

An example of this: 2 days prior to surgery, patients are reminded about the requirement to wash with hibaclens the night before surgery. Holista reaches out to ensure it’s use as dictated or surgery could be postponed or canceled. Other pre surgery guidelines not followed could cause a patient to become disqualified from the episode of care and therefore lose the incentive, as well as the employer suffering unknown and typically much higher cost from other surgical resources such as a health system.

The most recent element in Holista’s strategy and story came to fruition in 2023 with the addition of an insurance component to cover physician risk. Physicians were reluctant to guarantee a fixed price knowing full well potential case variance. Now with Holista’s innovative approach and laser focus on quality outcomes, true guaranteed episode of care offerings can be realized.

Obstetrics, gastroenterology, podiatry – 250 episodes of care have been designed with most fully in use in multiple states. Kate and Holista have their eyes set on chronic disease based, longitudinal episodes – a truly innovative approach to total cost of care. 

To Learn More Please Contact Craig Evans