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Stacey Schulz, MBA Sr. Contract Manager UnityPoint Health - Meriter
Bundled Payments Stephanie Cain, APN, DNP Advanced Practice Nurse - Colorectal Center UnityPoint Health Peoria- Methodist Medical Center Stacey Schulz, MBA Sr. Contract Manager UnityPoint Health - Meriter
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Purpose & Learning Objectives
Bundled Payments Purpose & Learning Objectives Give an overview of Bundled Payment initiatives at UnityPoint - Meriter and UnityPoint - Peoria Methodist What are Bundled Payments? How do we structure a Bundled Payment Program? What is impact of Bundled Payments on delivery of Care?
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Fee For Service Payments
Bundled Payments Fee For Service Payments Separate payments for each service during a single illness or course of treatment Fragmented provision of care Minimal coordination across providers and health care settings Rewards quantity vs. quality
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What are Bundled Payments?
A lump sum payment for an entire episode of care More coordinated care Higher quality outcomes Lower cost to payors/patients Opportunity to align incentives for providers across the care continuum
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Available Opportunities
Bundled Payments Available Opportunities Partnership for Healthcare Payment Reform – Private Payor Bundle Pilot Center for Medicare and Medicaid Innovation (CMMI)’s Bundled Payments for Care Improvement Initiative (BPCI)
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Bundled Payments PHPR Initiative sponsored by the Wisconsin Health Information Organization: provide superior healthcare at affordable costs Total Knee Replacement Pilot Bundled Payment with a private payor Collaborative communication and feedback amongst participants (providers and payors) Ability to design episode of care and required performance measures As conversations ensued with PHPR, information became available regarding a bundled payment initiative offered by CMMI If we were going to dip our toe in the water with one initiative, we felt we could leverage our efforts to support two
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CMMI – Bundled Payments for Care Improvement Initiative
Four innovative payment models Financial and performance accountability measures Care redesign/enhancements Evidence-based medicine Standardized operating protocols Improved care transitions Potential to gainshare CMMI
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Bundled Payments : CMMI
BPCI Models of Care Model 1: Retrospective Acute Care Hospital Stay Only Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care Model 3: Retrospective Post-Acute Care Only Model 4: Prospective Acute Care Hospital Stay Only
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Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care
Bundled Payments: Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care 48 Episodes (MS-DRG severity family) to select from Post-Acute Episode Length 30, 60, or 90 days 3% discount for 30 and 60 days 2% discount for 90 days Risk Track for Outliers A: 1/99, B: 5/95, C: 5/75 Responsible for 20% of episode payments above the high-end threshold Model 2 Waivers Payment Policy Waivers 3-Day Stay Requirement for SNF Payment Post-Discharge Home Visit Telehealth Fraud and Abuse Waivers Savings Pool Contribution Waiver Incentive Payments Waiver Group Practice Gainsharing Waiver Patient Engagement Incentive Waiver Currently 107 Participants
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BPCI Model 2 - Meriter 90 days, 2% discount Risk Track B (5/95)
Bundled Payments: BPCI Model 2 - Meriter Major joint replacement of the lower extremity MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complication or comorbidity MS-DRG 470: Major joint replacement or reattachment of lower extremity without major complication or comorbidity 90 days, 2% discount Risk Track B (5/95) Fraud and Abuse Waivers Savings Pool Contribution Waiver Incentive Payments Waiver Group Practice Gainsharing Waiver Live: January 1, 2014
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Historical Hospital Claim Data
Bundled Payment CMS Pricing Rules Update Factors Area Wage Index Historical Hospital Claim Data Risk Tracks National Case-mix Weights Low Volume Adjustment Apply Case-mix Discount Adjustments Target Price $ End Result = Add-on payments are paid normally per IPPS IME/DSH are not included in Target Price
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Post-Episode Spending
Bundled Payments Post-Episode Spending CMS will perform a Post-Episode Spending Calculation for the 30-Day Post-Discharge period after an episode ends Total expenditures during the 30-Day Post-Episode period exceeding the Risk Threshold (5/95), is excess spending that must be repaid.
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Net Payment Reconciliation Amount
Bundled Payments Net Payment Reconciliation Amount Target Price Aggregate FFS Payment Net Payment Reconciliation Amount
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Opportunity to Gainshare
Bundled Payments Opportunity to Gainshare Model 2 Fraud and Abuse Waivers allow the development of a Gainsharing Program to allow Awardees to share savings with providers/practitioners involved in Care Redesign for identified Episodes of Care Internal Cost Savings Positive Net Payment Reconciliation Amounts Hospitals now have an opportunity to share savings with independent or group practice physicians
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Gainsharing Program Requirements
Bundled Payments: Gainsharing Program Requirements Ensure care is not inappropriately reduced Maintain or improve quality of care No inappropriate change in utilization or referral patterns Protect against fraud, waste, and abuse
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Bundled Payment Process
Bundled Payments Bundled Payment Process Convene an interdisciplinary team Define the episode of care Develop performance measures Financial Quality Create model of care Price the episode of care Identify cost reduction opportunities Develop gainsharing program Foster a continuous process improvement plan
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Interdisciplinary Team
Bundled Payments Interdisciplinary Team Designed to develop and monitor the episode of care and performance Legal/Policy Clinical Leaders: inpatient, surgical, therapy, post-acute care Quality/Performance Improvement Finance/Data analysis Administration Physicians Core members to develop and monitor the bundled payment episode of care and performance
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We Demonstrated Solidarity We included them in the process.
Turning Physician Interest into Engagement Monthly Meetings We Demonstrated Solidarity We Asked for Help We Brought Data For the first time, physicians were able to see how they were performing not only as an individual, but also relative to their peers. We were transparent. Physicians walked into a room with a room full of administrative and operational power. We were committed. Throughout the course of the meetings, we asked for the physicians to help us design the bundle. We included them in the process.
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Define the Episode of Care
Bundled Payments Define the Episode of Care Define episode parameters Included services and items Excluded services or items Related Post-Acute Care Length of Episode Qualification Criteria Eligibility criteria Ex: Age, limitations of co-morbidities, etc. Outlier Protection Understand where outlier risk resides Episode development and model of care manages clinical risk not probability risk
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Develop Performance Measures
Bundled Payments Develop Performance Measures Aim to balance cost and quality outcomes Complete analysis of “baseline” cost of episode of care “Cost” defined as real cost Segregate variable cost to model volume risk Assign Target Cost for purposes of gainsharing (if applicable) Determine quality measures Revision rates Pain scores Patient satisfaction scores Return to functionality assessments (KOOS/WOMAC)
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Bundled Payments
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Monitoring and Tracking Data
Bundled Payments Monitoring and Tracking Data Develop a mechanism for tracking data Systematize processes Communicate outcomes and results timely Question outliers and idiosyncrasies Learn from them and adjust processes, screenings, communications, etc. accordingly Consider sample size Need an “n” that is significant
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Data Analysis Challenge: Linking Disparate Data
Acute-Stay/ Discharge Surgery Post-Acute Care Pre-admission Physician Clinic Records Supply/ Purchasing Records Inpatient Stay Records Home Health Records Talking Points: To truly understand the patient experience across the continuum of care, we have to piece together many data points from many disparate sources, some of which are outside of our system walls One key point I want to emphasize: There is not one common unifying variable that is consistent throughout all of these sources, so linking the information turns into a vary labor intensive, manual process OR Records Pharmacy Records Insurance Records Anesthesia Records Quality Records Therapy Records Records that are owned by other entities
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Create Model of Care Identify standards of care and best practices
Bundled Payments Create Model of Care Identify standards of care and best practices Understand the cost variation for each component of service OR Implant Inpatient Therapy Home Care SNF Readmissions Facilitate conversations to identify opportunities by comparing peer-to-peer and against best practice guidelines Share data and let the data speak for itself Identify physician champions Solicit supporting documentation/educational articles, etc.
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Pre-bundle Patient Care
Surgery/ Acute Stay Post-Acute Care Pre-admission Discharge Before working on bundles, Meriter and its partner organizations provided great patient care, but it was always focused within the immediate “silo” the patient was in.
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Post-bundle Patient Care
Surgery/ Acute Stay Post-Acute Care Pre-admission Discharge The Value of Working Across a Continuum of Care: Growing partnership for all stakeholders throughout patients’ continuum of care Increased physician and nursing collaboration to ensure quality care Increased focus on practicing evidenced-based care Improved coordination of care with internal and external stakeholders Increased focus on appropriateness of post-acute care Increased stakeholder awareness for how to deliver high quality, lower cost care
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Price the Episode of Care
Bundled Payments Price the Episode of Care Define baseline/target price for bundle CMMI factor in discount Private payor factor in margin Assess outliers CMMI Risk Track Provision for outliers with private payor or manage risk with eligibility criteria Prospective vs. Retrospective Prospective requires distribution of payments to episode of care providers Retrospective requires reconciliation and settling Determine frequency of analysis and reconciliation to settle and close episodes
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Identify Cost Reduction Opportunities
Bundled Payments Identify Cost Reduction Opportunities Understand the detailed cost for each component of the bundle Review standardization opportunities Major: anesthesiology method Minor: updating physician preference card Define key cost components to monitor and track Inpatient Costs Surgical Costs Implant Costs Sum of Variable Costs Readmission Emergency Room Skilled Nursing Facility Home Health Outpatient Therapy
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2012 Meriter Discharge Data (MS-DRG 470)
% D/C Home with OP Follow-up % D/C to SNF % D/C with Home Care % D/C Other PPIC Patients 29.5% 30.1% 39.9% .5% Medicare Patients 14.2% 60.3% 21.4% 4.1% Combined Patients (PPIC + Medicare) 19.1% 50.5% 27.4% 3.0% Nationally, Medicare Post-TKA SNF discharge rates average between 37-45% SNF discharge percentages highly variable across Meriter orthopedic providers (11% to 71%) A recent inpatient chart review of 15 PPIC patients discharged to Skilled Nursing Facilities revealed the following: 7 of the 15 patients reviewed had mobility limitations or lack of support at home that met skilled criteria for SNF admission 8 of the 15 patients were transferring and ambulating without physical assistance prior to acute care discharge and had a spouse or other caregiver available to provide support. Questionable whether skilled criteria met.
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Meriter’s Gainsharing Mechanism
Bundled Payments Meriter’s Gainsharing Mechanism Group Circuit Breakers Eliminate payment to the whole group if quality materially declined Individual Circuit Breakers Eliminate individual physician’s payment if defined performance measures are not met, or materially declined Group: Quality: KOOS scores, post-operative pain scores, Surgical Care Improvement Project scores (decline by more than 2 standard deviations from baseline) Incentive Breakpoint Individual: “sentinel” Joint Commission quality event, Related readmission, meeting attendance, Abide by Policy on Conservative Measures
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Gainsharing Mechanism
Bundled Payments Gainsharing Mechanism Required Savings 3% CMS Target Price Allows coverage for administrative costs Additional Savings to be shared 50% with Hospital and 50% with Physicians Qualifying Cases Payouts are determined based on number of qualified cases Qualifications are based on criteria and standards set by the group Pain Management Implants LOS OR efficiency, etc. Physicians can make the best decision for an individual patient and may lose a portion (qualified case) of gain-sharing but is not automatically forfeiting any incentive for the period
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Foster Continuous Improvement
Bundled Payments Foster Continuous Improvement Quarterly Interdisciplinary Team Meetings Report Outcomes Review Variances Introduce Ideas or Opportunities Performance Dashboard Ongoing review and response to variances or changes in cost or quality data Open communication and discussion of industry articles and research
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Online Guided CarePath: Wellbe.me
Bundled Payments Online Guided CarePath: Wellbe.me Tool that provides patients with checklists of activities they need to complete at each stage of their episode of care.
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Private Payor Considerations
Bundled Payments Private Payor Considerations Ability to develop contractual provisions Compliance Termination Available and applicable waivers Claims processing Applicable restrictions
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Bundled Payments CMS Bundled Payment Initiative UnityPoint Health Peoria Methodist Medical Center Methodist has selected to be paid a bundled rate for major bowel procedures which includes DRGs 329, 330 and 331. (colon resection primary) Under the bundled payment initiative, Part A & B services are bundled beginning on the first three days prior to hospital admission through 90 days post discharge. Providers continue to bill Medicare under fee-for-service. At the end of each contract year, a retrospective reconciliation occurs against the target price. Methodist selected Risk Tract 2 and launched Oct 1, 2013 Methodist is also a medical shared savings participant with 11,000 attributed members.
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Methodist Triple Aim Objectives
Bundled Payments Methodist Triple Aim Objectives Improve clinical outcomes of bowel resection patients. Coordinate patient care across the continuum to reduce readmissions, unnecessary testing, and patients adherence to recommended care. Improve the patient’s experience as measured by HCAHPS scores. Increase physician satisfaction through participation in the care redesign process, outcome measurement and economic alignment. Improve operating efficiency resulting in lower costs.
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Peoria Bundle Components
Bundled Payments Peoria Bundle Components Physicians’ services Inpatient hospital services (episode anchor) Inpatient hospital readmission services Long term care hospital services (LTCH) Inpatient rehabilitation facility services Skilled nursing facility services (SNF) Home health agency services (HHS) Hospital outpatient services Independent outpatient therapy services Clinical laboratory services Durable medical equipment Part B drugs
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Private Payor Considerations
Bundled Payments Private Payor Considerations Ability to develop contractual provisions Compliance Termination Available and applicable waivers Claims processing Applicable restrictions
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Top Initiatives to support project
Started engaging surgeons 5 months before project started Weekly meetings; data; 1:1 meetings Shared baseline data early on so all new current situation and opportunity Included in design of gain share model, metrics, and dashboard design Saw need to hire colorectal NP navigator (dual role Bundled project and launch colorectal cancer center) Invested time in gaining surgeon consensus on order sets, processes and procedures
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Top Initiatives to support project
Engaged wide stakeholder groups Nursing units Administration PI analyst Finance Case management Coders OR staff Schedulers Surgeon office staff Primary care providers LTC’s
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Positive Outcomes Good engagement from surgeon groups
Good awareness and adherence to processes sets from OR and nursing staff OR staff asking about opening expensive items Nursing staff and getting patients moving quicker and setting discharge expectations
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Positive Outcomes Internal cost savings being achieved
ICU LOS and overall LOS down Cost per Case down (supplies in OR) Decreased Surgical Site Infection Navigator working well Patients like having navigator at the hub Surgeons like navigator to round and provide updates and recommendations
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Outcome Data (first four months)
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Outcome Data (first four months)
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Outcome Data (first four months)
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Outcome Data (first four months)
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Internal Cost Savings to date
Major Bowel Procedures CY 2012 Baseline (Inflated*) Rollup starting Oct 2013 Medicare only All Colon Bundle w/ Medicare Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 n= 55 29 3 11 2 7 4 ALOS 7.7 7.1 5.7 9.1 4.5 6.7 7.25 Avg Cost/Case $19,712 $16,974 13,652 22,048 13,884 13,555 18,018 7,022 Avg Supply Cost/Case $5,186 $3,677 2,684 4,721 3,505 3,206 3,244 2,107 Mortality 1 Estimated Savings (green) -79,408 -18,181 25,694 -11,656 -43,100 -6,777 -32,402 ICU as part of stay 15 5 ALOS for entire visit 12.6 9.4 5.0 12.0 8 10.5 ALOS in ICU 2.8 1.0 3.0 3.5 Avg Cost/Case for entire visit $30,453 $22,634 14,682 27,981 15,471 18,821 22,704 Avg Supp Cost/Case entire visit $6,842 $3,478 2,665 4,181 3,427 1,469 3,563 Avg Cost/Day in ICU $1,788 $1,802 1,775 2,027 1,408 1,534 1,598 Avg Supply Cost/Day in ICU $87 $83 82 93 65 71 74 Pts without Complications 51 25 9 6 6.5 6.4 7.6 7.3 Cost/Case $16,972 $15,364 18,312 12,677 20,153 Supply Cost/Case $4,629 $3,743 4,667 3,496 3,774 % Pts w/out Complications 92.7% 86% 100 86 75
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Lessons learned and opportunities for growth
Major Bowel Procedures might not be the best to start with? Challenges Identification/Coding Surgeon called in to minor assist and it gets coded as bundle despite “not theirs”- perforated bowel Inclusion & Exclusion Criteria Elective vs. Emergent Cases and no pre-op screening and mitigation Would have hired the NP earlier 3 large outliers early on with long LOS- did not see in our 3 year look back like these three! This has been huge…they trust her and are letting her move pts sooner out of ICU, agree with her recommendations ect
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Lessons learned and opportunities for growth
Consensus takes time related to various surgeon practice preference related to training and beliefs Example- standardized antibiotic use, close vs. open decisions, use of wound vacs, how soon to do surgery vs. wait Surgeons who are on the bundled team are very engaged…they are not so good at getting the processes and information to their peers Requires going to offices periodically to review data metrics, and gain sharing Keeping them engaged is helps to have citizenship as part of gain share.
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Miscellaneous What/How is critical to helping manage?
Nurse Practitioner, PI, Case Managers What’s missing or challenging? Sometimes hard to know in the bundle or not? Patients presenting in crisis so poor outcomes Not able to take advantage of the SNF waiver due to the nature of the surgery not being 3 day initial LOS and not doing any direct admits post op at this time due to so few readmits that would be stable
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Bundled Payments Questions?
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