Presentation on theme: "Stacey Schulz, MBA Sr. Contract Manager UnityPoint Health - Meriter"— Presentation transcript:
1 Stacey Schulz, MBA Sr. Contract Manager UnityPoint Health - Meriter Bundled PaymentsStephanie Cain, APN, DNPAdvanced Practice Nurse - Colorectal CenterUnityPoint Health Peoria- Methodist Medical CenterStacey Schulz, MBASr. Contract ManagerUnityPoint Health - Meriter
2 Purpose & Learning Objectives Bundled PaymentsPurpose & Learning ObjectivesGive an overview of Bundled Payment initiatives at UnityPoint - Meriter and UnityPoint - Peoria MethodistWhat are Bundled Payments?How do we structure a Bundled Payment Program?What is impact of Bundled Payments on delivery of Care?
3 Fee For Service Payments Bundled PaymentsFee For Service PaymentsSeparate payments for each service during a single illness or course of treatmentFragmented provision of careMinimal coordination across providers and health care settingsRewards quantity vs. quality
4 What are Bundled Payments? A lump sum payment for an entire episode of careMore coordinated careHigher quality outcomesLower cost to payors/patientsOpportunity to align incentives for providers across the care continuum
5 Available Opportunities Bundled PaymentsAvailable OpportunitiesPartnership for Healthcare Payment Reform – Private Payor Bundle PilotCenter for Medicare and Medicaid Innovation (CMMI)’s Bundled Payments for Care Improvement Initiative (BPCI)
6 Bundled PaymentsPHPRInitiative sponsored by the Wisconsin Health Information Organization: provide superior healthcare at affordable costsTotal Knee Replacement PilotBundled Payment with a private payorCollaborative communication and feedback amongst participants (providers and payors)Ability to design episode of care and required performance measuresAs 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
7 CMMI – Bundled Payments for Care Improvement Initiative Four innovative payment modelsFinancial and performance accountability measuresCare redesign/enhancementsEvidence-based medicineStandardized operating protocolsImproved care transitionsPotential to gainshareCMMI
8 Bundled Payments : CMMI BPCI Models of CareModel 1: Retrospective Acute Care Hospital Stay OnlyModel 2: Retrospective Acute Care Hospital Stay plus Post-Acute CareModel 3: Retrospective Post-Acute Care OnlyModel 4: Prospective Acute Care Hospital Stay Only
9 Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care Bundled Payments:Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care48 Episodes (MS-DRG severity family) to select fromPost-Acute Episode Length30, 60, or 90 days3% discount for 30 and 60 days2% discount for 90 daysRisk Track for OutliersA: 1/99, B: 5/95, C: 5/75Responsible for 20% of episode payments above the high-end thresholdModel 2 WaiversPayment Policy Waivers3-Day Stay Requirement for SNF PaymentPost-Discharge Home VisitTelehealthFraud and Abuse WaiversSavings Pool Contribution WaiverIncentive Payments WaiverGroup Practice Gainsharing WaiverPatient Engagement Incentive WaiverCurrently 107 Participants
10 BPCI Model 2 - Meriter 90 days, 2% discount Risk Track B (5/95) Bundled Payments:BPCI Model 2 - MeriterMajor joint replacement of the lower extremityMS-DRG 469: Major joint replacement or reattachment of lower extremity with major complication or comorbidityMS-DRG 470: Major joint replacement or reattachment of lower extremity without major complication or comorbidity90 days, 2% discountRisk Track B (5/95)Fraud and Abuse WaiversSavings Pool Contribution WaiverIncentive Payments WaiverGroup Practice Gainsharing WaiverLive: January 1, 2014
11 Historical Hospital Claim Data Bundled PaymentCMS Pricing RulesUpdate FactorsArea Wage IndexHistorical Hospital Claim DataRisk TracksNational Case-mix WeightsLow Volume AdjustmentApplyCase-mixDiscountAdjustmentsTarget Price$End Result =Add-on payments are paid normally per IPPSIME/DSH are not included in Target Price
12 Post-Episode Spending Bundled PaymentsPost-Episode SpendingCMS will perform a Post-Episode Spending Calculation for the 30-Day Post-Discharge period after an episode endsTotal expenditures during the 30-Day Post-Episode period exceeding the Risk Threshold (5/95), is excess spending that must be repaid.
14 Opportunity to Gainshare Bundled PaymentsOpportunity to GainshareModel 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 CareInternal Cost SavingsPositive Net Payment Reconciliation AmountsHospitals now have an opportunity to share savings with independent or group practice physicians
15 Gainsharing Program Requirements Bundled Payments:Gainsharing Program RequirementsEnsure care is not inappropriately reducedMaintain or improve quality of careNo inappropriate change in utilization or referral patternsProtect against fraud, waste, and abuse
16 Bundled Payment Process Bundled PaymentsBundled Payment ProcessConvene an interdisciplinary teamDefine the episode of careDevelop performance measuresFinancialQualityCreate model of carePrice the episode of careIdentify cost reduction opportunitiesDevelop gainsharing programFoster a continuous process improvement plan
17 Interdisciplinary Team Bundled PaymentsInterdisciplinary TeamDesigned to develop and monitor the episode of care and performanceLegal/PolicyClinical Leaders: inpatient, surgical, therapy, post-acute careQuality/Performance ImprovementFinance/Data analysisAdministrationPhysiciansCore members to develop and monitor the bundled payment episode of care and performance
18 We Demonstrated Solidarity We included them in the process. Turning Physician Interest into EngagementMonthly MeetingsWe Demonstrated SolidarityWe Asked for HelpWe Brought DataFor 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.
19 Define the Episode of Care Bundled PaymentsDefine the Episode of CareDefine episode parametersIncluded services and itemsExcluded services or itemsRelated Post-Acute CareLength of EpisodeQualification CriteriaEligibility criteriaEx: Age, limitations of co-morbidities, etc.Outlier ProtectionUnderstand where outlier risk residesEpisode development and model of care manages clinical risk not probability risk
20 Develop Performance Measures Bundled PaymentsDevelop Performance MeasuresAim to balance cost and quality outcomesComplete analysis of “baseline” cost of episode of care“Cost” defined as real costSegregate variable cost to model volume riskAssign Target Cost for purposes of gainsharing (if applicable)Determine quality measuresRevision ratesPain scoresPatient satisfaction scoresReturn to functionality assessments (KOOS/WOMAC)
22 Monitoring and Tracking Data Bundled PaymentsMonitoring and Tracking DataDevelop a mechanism for tracking dataSystematize processesCommunicate outcomes and results timelyQuestion outliers and idiosyncrasiesLearn from them and adjust processes, screenings, communications, etc. accordinglyConsider sample sizeNeed an “n” that is significant
23 Data Analysis Challenge: Linking Disparate Data Acute-Stay/ DischargeSurgeryPost-Acute CarePre-admissionPhysician Clinic RecordsSupply/ Purchasing RecordsInpatient Stay RecordsHome Health RecordsTalking 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 wallsOne 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 processOR RecordsPharmacy RecordsInsurance RecordsAnesthesia RecordsQuality RecordsTherapy RecordsRecords that are owned by other entities
24 Create Model of Care Identify standards of care and best practices Bundled PaymentsCreate Model of CareIdentify standards of care and best practicesUnderstand the cost variation for each component of serviceORImplantInpatientTherapyHome CareSNFReadmissionsFacilitate conversations to identify opportunities by comparing peer-to-peer and against best practice guidelinesShare data and let the data speak for itselfIdentify physician championsSolicit supporting documentation/educational articles, etc.
25 Pre-bundle Patient Care Surgery/Acute StayPost-Acute CarePre-admissionDischargeBefore 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.
26 Post-bundle Patient Care Surgery/Acute StayPost-Acute CarePre-admissionDischargeThe Value of Working Across a Continuum of Care:Growing partnership for all stakeholders throughout patients’ continuum of careIncreased physician and nursing collaboration to ensure quality careIncreased focus on practicing evidenced-based careImproved coordination of care with internal and external stakeholdersIncreased focus on appropriateness of post-acute careIncreased stakeholder awareness for how to deliver high quality, lower cost care
27 Price the Episode of Care Bundled PaymentsPrice the Episode of CareDefine baseline/target price for bundleCMMI factor in discountPrivate payor factor in marginAssess outliersCMMI Risk TrackProvision for outliers with private payor or manage risk with eligibility criteriaProspective vs. RetrospectiveProspective requires distribution of payments to episode of care providersRetrospective requires reconciliation and settlingDetermine frequency of analysis and reconciliation to settle and close episodes
28 Identify Cost Reduction Opportunities Bundled PaymentsIdentify Cost Reduction OpportunitiesUnderstand the detailed cost for each component of the bundleReview standardization opportunitiesMajor: anesthesiology methodMinor: updating physician preference cardDefine key cost components to monitor and trackInpatient CostsSurgical CostsImplant CostsSum of Variable CostsReadmissionEmergency RoomSkilled Nursing FacilityHome HealthOutpatient Therapy
29 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 OtherPPIC Patients29.5%30.1%39.9%.5%Medicare Patients14.2%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 admission8 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.
30 Meriter’s Gainsharing Mechanism Bundled PaymentsMeriter’s Gainsharing MechanismGroup Circuit BreakersEliminate payment to the whole group if quality materially declinedIndividual Circuit BreakersEliminate individual physician’s payment if defined performance measures are not met, or materially declinedGroup: Quality: KOOS scores, post-operative pain scores, Surgical Care Improvement Project scores (decline by more than 2 standard deviations from baseline)Incentive BreakpointIndividual: “sentinel” Joint Commission quality event, Related readmission, meeting attendance, Abide by Policy on Conservative Measures
31 Gainsharing Mechanism Bundled PaymentsGainsharing MechanismRequired Savings3% CMS Target PriceAllows coverage for administrative costsAdditional Savings to be shared 50% with Hospital and 50% with PhysiciansQualifying CasesPayouts are determined based on number of qualified casesQualifications are based on criteria and standards set by the groupPain ManagementImplantsLOSOR 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
32 Foster Continuous Improvement Bundled PaymentsFoster Continuous ImprovementQuarterly Interdisciplinary Team MeetingsReport OutcomesReview VariancesIntroduce Ideas or OpportunitiesPerformance DashboardOngoing review and response to variances or changes in cost or quality dataOpen communication and discussion of industry articles and research
33 Online Guided CarePath: Wellbe.me Bundled PaymentsOnline Guided CarePath: Wellbe.meTool that provides patients with checklists of activities they need to complete at each stage of their episode of care.
34 Private Payor Considerations Bundled PaymentsPrivate Payor ConsiderationsAbility to develop contractual provisionsComplianceTerminationAvailable and applicable waiversClaims processingApplicable restrictions
35 Bundled PaymentsCMS Bundled Payment Initiative UnityPoint Health Peoria Methodist Medical CenterMethodist 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, 2013Methodist is also a medical shared savings participant with 11,000 attributed members.
36 Methodist Triple Aim Objectives Bundled PaymentsMethodist Triple Aim ObjectivesImprove 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.
37 Peoria Bundle Components Bundled PaymentsPeoria Bundle ComponentsPhysicians’ servicesInpatient hospital services (episode anchor)Inpatient hospital readmission servicesLong term care hospital services (LTCH)Inpatient rehabilitation facility servicesSkilled nursing facility services (SNF)Home health agency services (HHS)Hospital outpatient servicesIndependent outpatient therapy servicesClinical laboratory servicesDurable medical equipmentPart B drugs
38 Private Payor Considerations Bundled PaymentsPrivate Payor ConsiderationsAbility to develop contractual provisionsComplianceTerminationAvailable and applicable waiversClaims processingApplicable restrictions
39 Top Initiatives to support project Started engaging surgeons 5 months before project startedWeekly meetings; data; 1:1 meetingsShared baseline data early on so all new current situation and opportunityIncluded in design of gain share model, metrics, and dashboard designSaw 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
40 Top Initiatives to support project Engaged wide stakeholder groupsNursing unitsAdministrationPI analystFinanceCase managementCodersOR staffSchedulersSurgeon office staffPrimary care providersLTC’s
41 Positive Outcomes Good engagement from surgeon groups Good awareness and adherence to processes sets from OR and nursing staffOR staff asking about opening expensive itemsNursing staff and getting patients moving quicker and setting discharge expectations
42 Positive Outcomes Internal cost savings being achieved ICU LOS and overall LOS downCost per Case down (supplies in OR)Decreased Surgical Site InfectionNavigator working wellPatients like having navigator at the hubSurgeons like navigator to round and provide updates and recommendations
47 Internal Cost Savings to date Major Bowel ProceduresCY 2012 Baseline (Inflated*)Rollup starting Oct 2013Medicare onlyAll Colon Bundle w/ MedicareOct-13Nov-13Dec-13Jan-14Feb-14Mar-14n=5529311274ALOS126.96.36.199.188.8.131.52Avg Cost/Case$19,712$16,97413,65222,04813,88413,55518,0187,022Avg Supply Cost/Case$5,186$3,6772,6844,7213,5053,2063,2442,107Mortality1Estimated Savings (green)-79,408-18,18125,694-11,656-43,100-6,777-32,402ICU as part of stay155ALOS for entire visit12.69.45.012.0810.5ALOS in ICU2.81.03.03.5Avg Cost/Case for entire visit$30,453$22,63414,68227,98115,47118,82122,704Avg Supp Cost/Case entire visit$6,842$3,4782,6654,1813,4271,4693,563Avg Cost/Day in ICU$1,788$1,8021,7752,0271,4081,5341,598Avg Supply Cost/Day in ICU$87$838293657174Pts without Complications51259184.108.40.206.3Cost/Case$16,972$15,36418,31212,67720,153Supply Cost/Case$4,629$3,7434,6673,4963,774% Pts w/out Complications92.7%86%1008675
48 Lessons learned and opportunities for growth Major Bowel Procedures might not be the best to start with?ChallengesIdentification/CodingSurgeon called in to minor assist and it gets coded as bundle despite “not theirs”- perforated bowelInclusion & Exclusion CriteriaElective vs. Emergent Cases and no pre-op screening and mitigationWould have hired the NP earlier3 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
49 Lessons learned and opportunities for growth Consensus takes time related to various surgeon practice preference related to training and beliefsExample- standardized antibiotic use, close vs. open decisions, use of wound vacs, how soon to do surgery vs. waitSurgeons who are on the bundled team are very engaged…they are not so good at getting the processes and information to their peersRequires going to offices periodically to review data metrics, and gain sharingKeeping them engaged is helps to have citizenship as part of gain share.
50 Miscellaneous What/How is critical to helping manage? Nurse Practitioner, PI, Case ManagersWhat’s missing or challenging?Sometimes hard to know in the bundle or not?Patients presenting in crisis so poor outcomesNot 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