Bundled Payments in Healthcare: How Envision Healthcare is Leading the Way in a New Payment Philosophy

Posted on Fri, Dec 04, 2015
Bundled Payments in Healthcare: How Envision Healthcare is Leading the Way in a New Payment Philosophy

By Daniel Castillo, MD
Executive Vice President, Evolution Health

You know how insurance customers save money by bundling various types of coverage, or communications customers can get a discount combining phone, cable television and internet services? The same principle is now being used for healthcare.

The federal government has launched a new bundled payment initiative designed to manage costs for Medicare patients. Under the program, different organizations – for example, hospitals, post-acute care companies, private physicians and/or therapists – agree to payment arrangements that include financial and performance accountability for episodes of care. The aim is to provide higher quality, coordinated care across the spectrum, all at a lower cost for Medicare and the patient. So basically, you have improved outcomes and lower costs by having healthcare organizations work together to combine services and set pricing ahead of time.

Envision Healthcare is in a unique position to lead the way in this initiative – after all, Envision is the parent of EmCare, a hospital-based company; AMR, a pre-hospital care company; and Evolution Health, a post-acute care company. Envision already focuses on quality of care, and with its complete continuum of services, our company is at the forefront of bundled care.

Currently, the initiative includes four broadly-defined models of care. In two of them, Envision takes on risk by assuming responsibility for managing the cost of a portion of a patient’s care episode. In one of the models, care begins with a hospital admission (from an EmCare hospitalist) and continues through the post-acute recovery (via Evolution Health). AMR often provides community paramedics to manage any gaps in care as well. In a different model, care starts after the patient is discharged from the hospital. As Evolution Health patients, they have access to the Medical Command Center which utilizes Evolution’s nurse navigators, EmCare physicians and AMR caregivers.

The bundled payment initiative is important not just for the government and patients, but for Envision Healthcare. It’s a way to integrate Envision’s array of services in a more involved way. It’s all three of our companies – AMR, EmCare and Evolution Health – working together to improve value and care for our patients. Currently, Envision Healthcare is enacting the bundled payment philosophy in 34 different programs across the country. That number is certain to grow.

When healthcare moved from the fee-for-service model to the value-based purchasing model, Medicare put the emphasis on quality rather than volume. The natural byproduct of lower costs and improved care is improved patient satisfaction and reduced admissions. Healthcare organizations offer better value, which means more meaningful reimbursement. And the patient is happy to reduce costs and their length of stay in the hospital.

Envision Healthcare draws from a diverse team of clinicians to provide the right care when it’s needed, wherever the patient resides. With our scope of expertise and scale of operations, we are uniquely positioned to provide bundled payment solutions.


The Future of Hospital Medicine: The Tools and Integrations that are Shaping the Specialty

Posted on Fri, Nov 20, 2015

Francisco Loya, MD
CEO, EmCare Hospital Medicine


The technologies we are using to improve the delivery of care in hospital medicine are showing great promise – if not outright success. At EmCare Hospital Medicine, we are deploying various innovations that improve operational efficiency, enhance quality of care, ease staffing challenges and upgrade billing/coding practices. As these tech tools become more prevalent, I would argue that the future of hospital medicine has arrived, and with it the promise of better care and lower costs.


Operational Efficiency


The value-based purchasing environment has increased pressure on hospital medicine. The onus is largely on us to try and prevent readmissions while still being expedient with inpatient care and discharge to help increase patient satisfaction. Through automation, we have been able to reduce wait times for patients, streamline the admissions process and improve rounding and charge capture.

Through technology, we have created a platform for emergency physicians and hospitalists to meet and confer virtually so that the hospitalist may admit patients without having to visit the emergency department. This platform has allowed for a decrease in boarding times by 2.5 hours, an eight percent reduction in “Left without Treatment” rates and overall improvement (to nearly 100 percent) in Centers for Medicare & Medicaid Services core measure compliance. A by-product of the reduced wait times for patients is an increase in E.D. volume of nearly 27 percent. This has meant more volume for the hospital without any additional strain on resources.

Another technology we use coordinates admissions between hospitals and primary care physicians. This direct admit system is enacted with a click of a button by the primary care physician, who can then fill out an online form to admit the patient to the hospital. The platform also generates a “boarding pass” for the patient to bypass the E.D. and go straight to the inpatient floor. Not only does this technology improve cohesion between hospitals and primary care physicians, it also improves patient satisfaction since wait times are reduced. That in turn leads to a decrease in E.D. crowding and an increase to the hospital’s referral base.

These tools certainly don’t substitute for human interaction and can’t guarantee improved quality of care, but they do allow for greater control and management over various administrative protocols. The results from these tools have been positive – both for hospitals and patients. Doctors are able to increase their focus on patient care, and most hospital medicine support staff and caregivers have their jobs made easier and more efficient.




Telemedicine is another futuristic technology that’s growing in use and importance. Hospitalists are benefitting from virtual care and robotic caregivers that can help hospitals meet staffing and practice challenges.

“Five years ago, the technology wasn’t there,” said Angel Iscovich, M.D., a divisional CEO of staffing and innovation for EmCare. “The safeguards for patient privacy to protect encounters conducted over video just weren’t ready.”

Now we have cybersecurity that allows doctors to engage with patients via a video screen and webcam. The practice is easing staffing shortages for hospitals and putting patients at ease since they’re able to meet with highly-qualified specialists no matter where those physicians are.

Patients are also showing positive responses to robot doctors. Robots are slowly taking over rounding duties in some hospitals, acting as nocturnists that provide after-hours care. Companies that provide robodocs, such as InTouch Health, report that their robots can monitor heart sounds and connect to EMRs to improve care and efficiency. The robots are controlled with a tablet computer, so a caregiver can operate the robots on-site or the doctors can control the robots remotely for the virtual visits. The robots can easily round on the intensive care unit, interface with the equipment and provide more expedient and effective rounding than some of their human counterparts.

Cameras for the robodocs provide enough mobility and resolution to offer high-quality care. One doctor, through the use of video screens and robots, can cover multiple facilities while staying in one place. Hospitals can reduce costs by “sharing” the off-site physicians. And patient satisfaction scores have, so far, not suffered because of the technological intermediaries. If anything, early studies show that patients believe the robodocs and tele-visits allow them access to quality providers that otherwise would be unattainable.


Bundled Payment


The Bundled Payments for Care Improvement (BCPI) initiative is a federal government program designed to help manage costs for Medicare patients. BCPI allows disparate organizations to combine services and arrange for payment models that include financial and performance accountability for episodes of care. The program defines four broadly-defined models of care to include various combinations of pre-acute care, acute care and post-acute care.

With this recent inducement for organizations to work together, clinical integration is more important than ever – companies will need to attain certain levels of synergy outside of their own organizations. There are, however, some healthcare companies that are diversified enough to maximize the potential benefits of BCPI for themselves, their clients and patients. This type of self-integration tends to be more reliable because they have more control over more pieces of the BCPI integration – they are better able to manage quality of care across the care continuum. Through the integrated services – for example, a post-acute care company working with hospitalists – costs are reduced, which increases patient satisfaction since that patient is less likely to need readmitting and can receive care at home (where the patient generally prefers to be). With the cost offset, reimbursement from CMS can be more meaningful for the hospital as well.


Medical Command Center


Technology is allowing post-acute care companies greater control over the care offered in a patient’s home as webcams and video screens put caregivers face-to-face with patients. Our parent company, Envision Healthcare, has pioneered a new concept, the Medical Command Center that allows healthcare providers to check-in with patients to regulate prescriptions, check vitals and confirm operation of in-home medical devices. Medical Command Center staff use their high-tech control rooms to manage care for patients in a number of states and can quickly dispatch a caregiver such as a mobile integrated paramedic or physician assistant to a patient’s home when necessary.

These software advancements, tech tools and integrated services are becoming more pervasive as technology advances and providers find new ways to effectively integrate their services. By focusing on operational protocols such as admissions, rounding and discharge, along with streamlined billing practices and more seamless care, patients reap the benefits of high-quality personal care provided by caregivers while waiting less, paying less and visiting hospitals and doctors’ offices less.
By embracing the technologies that are available now and those that are on the horizon, hospitalists create more efficient practices for themselves and their patients, and are better able to focus on patient care, as opposed to the administrative processes that often keep us from the bedside - where many physicians prefer to be.


Evolution Health Enters Consumer-Facing On-Demand HealthCare Market

Posted on Mon, Nov 02, 2015

House calls were once a mainstay of the U.S. healthcare system. According to the American Academy of Family Physicians, in the 1930s, about 40 percent of all patient/physician encounters occurred in the home. That number declined steadily after WWII and by 1950, they only accounted for about 10 percent of patient encounters. Today, less than one percent of physician encounters occur in a home.

But that trend could be turning around. Medicare data shows that Part B billings for house calls increased by 60 percent from 1999 to 2009. That increase is thought to have been brought about by regulatory changes and a 50 percent increase in reimbursement. In the future, we’ll see more baby boomers entering their golden years and by 2030, 70 million Americans will be over 65. And more people will be living longer, many with disabilities that make it difficult to get to a doctor’s office.

A new healthcare delivery model has been developed to help fill that void. On-demand care connects patients with clinicians who provide care in the patient’s preferred setting, usually their home.

Evolution Health has been a leader in providing on-demand care through its mobile integrated healthcare service in locations throughout the country. On Nov. 1 Evolution Health started providing on-demand healthcare services to the retail market through its partnership with Pager, a consumer-facing mobile and virtual care service.

The partnership combines Pager’s patient‐centric technology with Evolution Health’s physician‐led, team‐based model of care and ensures comprehensive planned and unplanned care to patients across various care settings. Working with sister companies EmCare and American Medical Response, Evolution Health has access to unmatched clinical resources of more than 31,000 hospital based physicians, community‐based paramedics, nurses, advanced practice providers and other clinicians caring for more than 18 million patients annually across the nation.

“Evolution Health has intentionally designed a healthcare delivery system to improve the value of care based on the needs of a population, and that requires resources to provide both planned and unplanned care to improve health at that level,” said Eric Beck, DO, MPH, EMT‐P, CEO of Evolution Health. “Pager is an ideal partner for Evolution Health as we create a better healthcare experience through innovation, engagement technology and choice architecture.”

The partnership provides a unique opportunity for two pioneering companies to collaborate on delivering high quality care that is innovative, safe and easily accessible.

The service is now available in New York and San Francisco. Additional cities will added in 2016.


Doing More with Less: Biggest Challenges for Rural Healthcare

Posted on Fri, Oct 16, 2015
Doing More with Less: Biggest Challenges for Rural Healthcare

Bill Yarbrough, CEO
EmCare Physician Services

After nearly a quarter of a century of working with rural and community hospitals (most that report volumes of less than 15,000 a year), I have personally seen more hospitals in financial distress in the last several years than I have at any other time. I believe these struggles will be short-term, but that does remain to be seen due to the unknowns resulting from the Affordable Care Act’s (ACA) benefits to these types of hospitals. The biggest challenges for rural hospitals may be continuing to operate until these ACA results shake out. But for rural hospitals struggling in the current healthcare climate and waiting for the positive results of reform, there are things that can be done now.

Going it Alone
Rural hospitals not affiliated with a healthcare system may experience the greatest difficulties. Rural and community hospitals have a critical mission to the communities they serve and are often the only point of care for people in their areas. So when rural hospitals close, their communities suffer. One issue that rural and community hospitals can find challenging is trying to match resources and services with the larger metropolitan hospitals or healthcare systems. But many times, affiliating with these larger groups can help both parties – I’ve worked with such affiliations and they have strongly trended over the last ten years or so. It’s a mutually beneficial relationship - the system gains a presence in a new area while the rural facility gains resources, staffing, expertise and stability. There are a number of innovative arrangements where the relationship doesn't necessarily mandate a system of ownership or necessitate a changing of culture, but the parties simply share resources. There are also several of these agreements dealing solely with specialty care. When a hospital lacks care that a neighboring hospital has, the two can sometimes complement each other in terms of helping communities that are in close proximity.

Perhaps the greatest benefit for a larger hospital or system that agrees to partner with a rural hospital is the achievement of greater efficiency. In terms of HCAHPS scores or patient satisfaction metrics, I see a lot of rural and community hospitals scoring more favorably than their larger counterparts. This tends to indicate that rural and community hospitals have learned to do more with less, often through excellent Lean programs or other streamlined methodologies. That means that the larger for-profit systems and facilities as well as tertiary care hospitals are able to tap into their smaller affiliates for their effective efficiencies and modalities.

Meeting the Recruitment Challenge
Recruiting challenges aren’t limited to rural facilities. Recruiting for large 100,000 volume facilities can be just as challenging. Recruiting is actually EmCare’s bread and butter. Over the past 12 months we started up a number of new groups. Many times we had less than 60 days notice. Usually we have about 90 days, and in many cases we build those groups from scratch. We were able to staff these new practices in rural settings within a very short time frame. So rural recruiting can be done quickly, efficiently and very effectively.

One of the challenges of recruiting to smaller facilities is accessing potential hires. Our culture in general has gotten away from print and mail recruiting. Being able to communicate electronically and through social media and through networks and referrals are critical areas for recruiting. By embracing the newer virtual solutions, it becomes obvious that there are plenty of physicians who really want to affiliate with a quality organization and who want to work in a sustainable practice environment.

In my experience, in order to attract a physician to practice in a rural or community setting, hospitals should strive to be innovative in their packages and focus on promoting quality of life. There are so many beautiful communities around the country that are idyllic and wonderful, not only for raising a family, but also as professional practice opportunities. When you're talking specifically about rural administrators trying to attract somebody to come in and practice medicine, it's about putting the best selling points of the community out there in your recruiting materials. Physicians are looking for great practice opportunities, particularly if they're looking in a smaller community. They're looking for a more intimate practice experience and they want to practice long-term in these types of communities. So playing up the unique and quaint aspects of these wonderful locations can be a very successful tactic for recruiting.

I’ve seen facilities partner with their local chambers of commerce, put potential hires in touch with a great realtor and emphasize how much further their dollars can go in their market. These types of methods can go a long way when candidates come in to interview – the recruits feel welcome, they see how they could be embraced as part of the community.

After nearly 25 years of recruiting for rural hospitals, I am seeing the next generation of physician leadership emerge. One of the things that is personally fulfilling is watching the great energy and leadership brought by physicians that come out of residency programs. They are excited and stepping up and are going above and beyond to be part of the next great wave of physician leaders. The ability to step into a leadership opportunity can be a draw to smaller areas.

Adapting to Survive
Change for change sake isn't a good thing. In my experience, the most effective approach to positive change occurs when hospitals take a long hard look at themselves – or engage an objective, outside perspective – to identify what is currently negatively impacting that hospital.

One way to adapt is to offer specialty services. Patients like to stay close to their families, but if they need care that is not available at their local hospital, they will have to be transferred. No one is saying every rural hospital should have a neurologist, but by making sure there is a range of medical services - including surgery, outpatient surgery and certain specialty care - more patients could stay in the community rather than traveling a hundred miles away from their families. That improves the quality of care and satisfaction of care for everybody. It also enhances the reputation of the hospital.

Somebody once told me that you can either be an aircraft carrier or a speedboat, meaning that there are changes, whether in business or in life, that can be turned around more quickly than others. There are some major advantages to being a speedboat. Smaller vessels have the advantage of being able to change and adapt to evolving environments more quickly, as opposed to being part of a massive system where adaptations can roll out slowly. The key is to turn in the right direction.


A Patient-Centered Approach to Better Care

Posted on Fri, Oct 02, 2015
A Patient-Centered Approach to Better Care

Bill Edwards, R.N., M.S.
Senior Vice President of National Clinical Quality Strategy, Evolution Health


The Institute of Medicine defines patient-centered care as: "Respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions." Patient-centered care is a journey that moves decision-making directly to the individual despite frailty, cognitive impairment or the location in which services are provided. It includes the valuable input of care partners and integrates all aspects of daily life, creating environments where people can fully thrive and grow.


Patient-centered care improves access to care, efficiency of care and coordination of care, resulting in improved quality of care. Patients are supported in achieving the level of physical, mental and psychosocial well-being that is individually practicable. This goal honors the importance of keeping the person in the center of the care planning and decision-making process. Care plans are living documents that are revised to reflect a person’s changing needs.


In patient-centered care, clinicians and care providers place a premium on active listening and observing so they can readily adapt to each patient’s unique needs, regardless of cognitive abilities and physical limitations. Patient-centered care is more about focusing on the patient’s needs, wants and individual lifestyle. It is about giving people the tools to take control of their own health through products and directives that they can maintain between periodic visits with their primary care clinician.


As clinicians we talk about the behavioral changes necessary for a patient to benefit from our education and counseling, but what about the changes that we also must make? While clinicians possess the clinical expertise to care for patients, we should also view patients as equals and experts. After all, patients bring their personal knowledge and experience regarding the alignment of different treatment options and action plans with their values and preferences. They know best how well their healthcare providers are meeting their needs and expectations, and this view directly correlates with patient outcomes and patient satisfaction.


At Evolution Health, we’re committed to improving both the health of individual patients and populations. Providing patient-centered care helps us achieve that goal. We promote active patient engagement at every level of care design and implementation. We also utilize a holistic approach, coordinating care, enhancing communication, providing support, empowering the patient and ensuring ready access to care.


Patients want a personal relationship with their caregivers, communication and empathy. A patient-centered approach gives you the opportunity to provide that and much, much more. Our patients deserve no less.


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