Medicare Gainsharing Program Recognized and Approved by CMS.

AMS provides the gainsharing component in the largest Medicare Gainsharing Demonstration – BPCI Model 1. AMS PBIS^® is the only broad based, comprehensive gainsharing methodology currently approved by CMS.

Program Objectives Met. Expansion Underway.

New Jersey Hospital Association(NJHA) – Measured success in the first 3 years has led to an expansion of the program under the Medicare BPCI Model 1 initiative. As of April 1, 2013, the 12 hospital demonstration was completed and the Model 1 Gainsharing Program began with 23 hospitals participating.
Greater New York Hospital Association (GNYHA) – The success of the Continuum Health Partners program led to GNYHA’s interest in offering the program to its membership. The program began in 2012 and now has 14 hospitals with additional hospitals added quarterly. All participating hospitals are achieving cost reductions, as well as driving quality improvement initiatives.
The Hospital and Healthsystem Association of Pennsylvania (HAP) and Florida Hospital Association (FHA) are implementing the commercial gainsharing program for member hospitals.
The Maryland Hospital Association is implementing a gainsharing program that works within Maryland’s all payor system. It will be the first gainsharing initiative that will encompass Medicare, Medicaid, and commercial patients.

Since AMS introduced AMS PBIS^® in 2006, hospital/physician alignment has not only provided financial benefit for hospitals and physicians, but also is viewed as a tool to improve quality scores on targeted initiatives. In addition, the program integrates into broader population health initiatives that hospitals may be considering.

Gainsharing: Proven Physician Participation, Hospital Cost Reduction with Hospital Quality Maintained.

A 2010 Journal of Hospital Medicine (PDF) article describes in depth AMS’ 36 month project with Continuum Health Partners, a multi-hospital system in New York including Beth Israel Medical Center – Petrie, Beth Israel Medical Center – Kings Highway, St. Luke’s Hospital and Roosevelt Hospital. (Note: Effective October 2013, Continuum became part of the Mount Sinai Health System.)

Continuum instituted the AMS Gainsharing Program in 2006 and the program is still operating. For the year prior to initiating the program, AMS developed baseline length of stay (LOS) and case costs. Best practice norms (BPNs) were established at the top 25^th percentile of physicians for each All Patient Refined Diagnosis Related Group (APR DRG). Hospital costs, in several areas, including operating room charge (OR), supplies and implants, nursing and per-diem room costs were analyzed. Payments were based upon case level performance compared to BPNs and the physician’s historic performance. Eligible cases included commercial insurance only for the first two years but Medicare cases were included after October 2008 resulting from a Centers for Medicare and Medicaid Services (CMS)-approved demonstration project. Payments to physicians required meeting quality thresholds, including chart completion and compliance with core measures.

Continuum enrolled 54% of its physicians into the program. Hospital costs were reduced by $25.1 million during the 3 years, with most cost reduction attributed to reduced LOS and medical supply costs. Physician payouts averaged $1,866 per physician per quarter. And delinquent medical records decreased over 10%.

$113 Million Cost Reductions in a 36 month / 12 Hospital New Jersey Medicare Demo.

A 2009 to 2013 Medicare Gainsharing Demonstration, facilitated by NJHA, comprising 12 hospitals, 1,200 participating physicians and 137,000 Medicare admissions resulted in $113 million cumulative savings, $822 per admission or 8.5%. Savings are attributable to the efforts of the participating hospitals and the participating physicians.

(Note: Savings analysis is a comparison of actual cost to base year cost adjusted for inflation and case-mix (i.e. expected cost). The statements contained in this document are solely those of AMS and do not necessarily reflect the views or policies of CMS.)