ESTRATEGIA DE PAGO INTEGRAL PARA COLUMNA

Brian Asmussen, MBADirector de Soluciones EstratégicasMedtronicDallas, Texas, EE. UU.

BUNDLED PAYMENT OVERVIEW AND CASE STUDY FOR SPINE

AGENDABundled Payments Overview

Defining your Bundle

Case Study: University of X Spine Bundle

BUNDLED PAYMENT OVERVIEW AND CASE STUDY FOR SPINE

AGENDA Defining your Bundle

Case Study: University of X Spine Bundle

Bundled Payments Overview

WHAT ARE BUNDLED PAYMENTS?

REDEFINING THE ACUTE CARE EPISODEBUNDLED PAYMENTS DRIVE DELIVERY SYSTEM INTEGRATION

Individual Payments Reinforce Siloed Care Delivery

Fee-for-Service Environment Bundled Payment EnvironmentLump Sum Payments Drive Integration

through Shared Accountability

Payer

Physician Services

Hospital Services

Post-Acute Services

Payer

Physician Services

Hospital Services

Post-Acute Services

Bundled payment programs set a single payment amount for a period or episode of care

All care provided to the patient during that episode is included in the bundle and becomes the responsibility of the bundle holder (provider)

Bundles are often tied to a procedure or treatment for a particular condition; the initiation of the procedure or treatment triggers the bundle

The payment for the bundle is typically set below historical spending for that episode (target price)

Bundle holders are financially accountable for any spending above the preset target price

To be successful under bundled payments, providers must reduce spending during the episode by reducing inefficiencies (e.g. avoidable readmissions), changing care pathways and provider types used, and improving care

Bundled payment participants who achieve savings beyond the target price may keep the difference

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Long-Term Acute Care Hospital

Inpatient Hospital Readmissions

Physician Services

Durable Medical Equipment (DME)

Inpatient Rehabilitation

Facility

Home Health Agency

Other Hospital Outpatient

Services

Part B Drugs

Skilled Nursing Facility

Hospice Services Clinical Laboratory

Services

Anchor Inpatient Stay or Outpatient Anchor Procedure

Discharge

Episode Trigger 90 days

3 DaysPre-Acute1

Hospital Inpatient Stay

Inpatient MD Services

Post-Acute Facility Services

Post-Acute MD Services

Related Readmissions

Model 1

Model 2

Model 3

Model 4

BUNDLING IS A SINGLE PAYMENT FOR AN ARRAY OF SERVICESACROSS EXTENDED TIME HORIZONS AND SITES OF CARE

NEUROSCIENCE BUNDLES IN UNITED STATES PUBLIC SYSTEM FOCUS ON SPINE & STROKE

1

INPATIENT CLINICAL EPISODES

Orthopedic Cardiology Gastrointestinal

• Double joint replacement of the lower extremity• Major joint replacement of the lower extremity¹• Major joint replacement of the upper extremity • Fractures of the femur and hip or pelvis• Hip & femur procedures except major joint• Lower extremity/humerusprocedure except

hip, foot, femur• Spinal fusion (non-cervical)• Cervical spinal fusion• Combined anterior posterior spinal fusion• Back & neck except spinal fusion

• Cardiac arrhythmia• Cardiac Defibrillator• Cardiac Valve• Pacemaker• Percutaneous coronary intervention• Coronary artery bypass graft• Congestive heart failure• Acute myocardial infarction• Transcatheter Aortic Value Replacement²

• Gastrointestinal hemorrhage• Gastrointestinal obstruction• Major bowel procedure• Disorders of the liver excluding malignancy,

cirrhosis, alcoholic hepatitis • Bariatric Surgery²• Inflammatory Bowel Disease²

Pulmonary Neurological Infectious

• Simple pneumonia and respiratory infections• COPD, bronchitis, asthma

• Seizures²• Stroke

• Cellulitis• Sepsis• Urinary Tract Infection

Kidney

• Renal Failure

¹Identical to the CJR clinical episode; CJR will take precedence over BPCI Advanced² New for Model Year 3

OUTPATIENT CLINICAL EPISODES• Cardiac Defibrillator• Percutaneous coronary intervention• Back & neck except spinal fusion• Major joint replacement of the lower extremity (MJRLE) ²

BUNDLED PAYMENT OVERVIEW AND CASE STUDY FOR SPINE

AGENDA

Case Study: University of X Spine Bundle

Bundled Payments Overview

Defining your Bundle

Total SpendParticipant Gain/Loss

Historical Baseline

$50,000

Scenario 1: Service Avoidance

$30,000 $18,500

Scenario 2: Inappropriate Service Avoidance

$80,000 -$31,500

Scenario 3: Service Substitution

$25,000 $23,500

Scenario 4: Unsuccessful Service Substitution

$60,000 -$11,500

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Target Price: $48,500

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SNFIRF

PhysicianHHA

Home

Telehealth

Hospital

Hospital

Hospital

Hospital

Hospital

SNF

SNF

Home

Home

Home

HHA

HHA

Hospital

Physician

Physician

90 days

HHA

SNF Telehealth Home PhysicianHospital

TO BE SUCCESSFUL IN BUNDLED PAYMENTS, PROVIDERS NEED TO CHANGE WHAT TYPE OF CARE IS PROVIDED WITH THE GOAL OF GETTING PATIENTS HOME QUICKLY AND SAFELY ILLUSTRATIVE EXAMPLES OF PERFORMANCE UNDER BUNDLED PAYMENT

PRICING STRATEGY BASED ON HISTORIC BENCHMARKS WITH ADJUSTMENTS FOR PATIENT MIX AND SPENDING TRENDS AMONG PEER GROUPS

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Target Price

Patient Case Mix

Peer Group Comparison

Historical Efficiency

Compares actual spending to adjusted national spending

AMC/Non‐AMC Urban/rural Safety Net vs. not Census region Bed size

HCCs DRGs Demographics Dual‐eligibility Institutional status

Source: CMS. BPCI Advanced Conceptual Overview, January 2018. Available at: https://innovation.cms.gov/Files/slides/bpciadvanced-wc-conceptualoverview-slides.pdf

ADVANCED QUALITY MEASURES

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APPLICABLE EPISODES QUALITY MEASUREAll Inpatient and Outpatient Episodes NQF #1789 Hospital Based All-cause Hospital Readmission Measure

NQF#0326 Physician Based Advanced Care Plan*

NQF #0531 Hospital Based CMS Patient Safety Indicators (PSI)

Double Joint Replacement of the Lower Extremity; Major Joint Replacement of the Lower Extremity

NQF:# 1550 Hospital Based Hospital-level Risk-Standardized Complication Rate (RSCR) Following Elective Primary THA and/or TKA

CABG NQF #2558 Hospital Based Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG

AMI NQF #2881 Hospital Based Excess Days in Acute Care after Hospitalization for AMI

Back and Neck Except Spinal Fusion (Inpatient and Outpatient); Cervical Spinal Fusion; Combined Anterior Posterior Spinal Fusion; CABG; Double Joint Replacement of the Lower Extremity; Hip and Femur Procedures Except Major Joint; Lower Extremity and Humerus Procedure Except Hip, Food, Femur; Major Bowel Procedure; Major Joint Replacement of the Lower Extremity; Major Joint Replacement of the Upper Extremity; Cardiac Valve

NQF #0268 Physician Based Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin

Quality measures may be updated by CMS on an annual basis (next update January 1, 2020); the first set of measures are claims-based and do not require any additional reporting on part of participants

*This measure was changed for use in the BPCI Advanced model and NQF has not reviewed or approved the revised measure specificationsSource: CMS BPCI Advanced Clinical Episode Reconciliation Specifications Model Years 1 and 2. June 2018. Available at: https://innovation.cms.gov/Files/x/bpciadvanced-reconciliation-my1-2.pdf

BUNDLED PAYMENT OVERVIEW AND CASE STUDY FOR SPINE

AGENDABundled Payments Overview

Defining your Bundle

Case Study: University of X

EXECUTIVE SUMMARY

DEFININGFUTURE

Scalable model for bundled payments

Operationalizingadvanced care planning & formalize post acute care strategy

Ongoing financial analysis & predictive modeling pilot

DELIVERINGRESULTS

Multidisciplinary spine council alignment focused on care redesign

Positive quality & financial trends

Sustained physician, administration, and staff engagement

DRIVINGCHANGE

Market trends leading to value based incentives

Spine surgery nationally and locally have high variation in care and cost

Build experience in alternative payment models

PARTNERSHIP VALUE

Access to incremental resources & expertise to implement a bundle payment program & track clinical & fiscal performance

Access to an environment for the development of spine bundle payment strategies, skillsets & business models

Data & insights needed to:

Reduce treatment cost by improving system & resource efficiencies

Increase access & care delivery to appropriate patients

Create standardized dashboards to routinely monitor clinical & fiscal performance & modify care continuum practices as needed

Data & insights needed to:

Understand the complexities & challenges of managing a 90 day spine episode of care

Explore risk-sharing business models

Build trust to facilitate formation of broader partnership opportunities

University of X

OBJECTIVES:

Identify strategic challenges & areas for improvement in the delivery of spinal care

Establish a successful bundled payment program under Medicare BPCI Advanced

Assessment Areas:

Inpatient & outpatient spinal procedures

Neurosurgery & Orthopedic Surgery

Surgery decision to 90-days post discharge

WHY SPINE SURGERY?

NEED FOR QUALITY & VALUE IMPROVEMENTS

NATIONAL VARIATIONS IN

QUALITY & COST

LOCAL VARIATIONS IN

CLINICAL PROCESSES

ESCALATING VOLUMES &

COSTS

PROJECT OVERVIEW

WORKSTREAMS

CARE PROCESS OPTIMIZATION

Identifies opportunities to improve efficiencies, enhance patient experience & decrease costs

FINANCIAL ASSESSMENT

Evaluates financials performance, coding & documentation accuracy & market share for the spine service line

POST ACUTE STRATEGY

Evaluates discharge process, pre-procedure identification of patient discharge needs, utilization & standardization for patients post spinal procedures

ENGAGEMENT & TELEHEALTH

Evaluates pre & post procedure patient engagement & determine need for additional solutions

DATA / ANALYTICS SUPPORT

Work collaboratively to utilize both UI & MDT data analytic capabilities for successful evaluation of operational, clinical, economic & strategic challenges in spine care

Key Milestone Key Action Items Status

Patient Tracking Capability Establish patient ID tracker

Performance Monitoring Capability

Baseline care & financial data

Service line variability analysis

Dashboard development & launch

Order Set Standardization Pre-op order set modifications

Cervical fusion order set modifications

Lumbar fusion order set modifications

Complex fusion order set modifications

Post op order set modifications

ACO Analysis ACO post-acute network analysis

ACO: network implementation

Risk Identification Pred. Analytics: complete retrospective analysis

Pred. Analytics: complete prospective model

Process Optimization Patient education updates

BPCI beneficiary notification requirements & workflow optimization

Advanced care planning

In-service training for faculty, staff & residents

CARE PATH REDESIGN PLAN

Complete

Delayed

At Risk

In Progress

Not Started

CARE COORDINATION/TRANSITIONS MANAGEMENT

BCPIBENEFICIARY NOTIFICATIONLETTER

Provide explanationabout the project

Educate patient and caregiver about discharge process and follow-up

CARECOORDINATION ASSESSMENT

Identify discharge barriers

Coordinate follow-up in specialty clinics & with PCP

Follow-up with facilities regarding transitions & clarifymedical needs for post facility discharge

PATIENTEDUCATION

Revised patient education booklet by combining information from Ortho & NSG

Updated patient discharge instructions by blending information from both Ortho & NSG

DISCHARGEFOLLOW-UPCALLS

Contact patient within 3 days if discharge home

Weekly contact with patient (at home or in facility) for first 30 days

Frequent call during 90 days post discharge

Collaborate with PCP in meeting post discharge medical needs

COST ANALYSIS OVERVIEW

VARIATION ANALYSIS

ENROLLMENT OVERVIEW & ACO IMPACT

KEY PERFORMANCE METRICS(AVERAGE LENGTH OF STAY & CASE MIX INDEX)

KEY PERFORMANCE METRICS(CC/MCC CAPTURE RATE)

ACTUAL SPEND VS TARGET PRICING [EPISODES 150 DAYS POST ANCHOR DISCHARGE (90 DAY EPISODE + 60 DAY CLAIM RUN-OUT)]

ACTUAL SPEND VS TARGET PRICING [EPISODES 150 DAYS POST ANCHOR DISCHARGE (90 DAY EPISODE + 60 DAY CLAIM RUN-OUT)]

PATIENT JOURNEY DASHBOARD[EPISODES 150 DAYS POST ANCHOR DISCHARGE (90 DAY EPISODE + 60 DAY CLAIM RUN-OUT)]

SUSTAINABILITY RESOURCES

PHASE OF CARE RESOURCE RESOURCE RESPONSIBILITY ANTICIPATED IMPACT

OUTPATIENT CLINIC Social Worker (1 FTE)

Discharge planning at point of indication

Reduce LOS

CONTINUUM OF CARE Spine Quality Resource CQSPI - data collection, outcomes resource

Improve outcomes. Enhanced marketing - increased

market share

INPATIENT Surgical Spine Patient Floor

Co-located Ortho & Neurosurgery spine patients to a single unit. Standardize workflow, reduce

testing, eliminate unnecessary costs.

Reduce LOS. Improve outcomes. Reduce ancillary costs

CONTINUUM OF CARE Additional Care Coordinator

Increase care coordination capacity Reduce LOS. Reduce readmission & returns to

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OUTPATIENT CLINIC Advance Care Planning Tools

Video decision aids/tablets Revenue opportunity

INPATIENT Dedicated Spine APP Improve patient throughput & improve documentation

Reduce LOS. Improve CC/MCC capture rates

CONTINUUM OF CARE Ortho & Neuro spine team ongoing engagement

Continued surgeon & resident engagement

Continued improvement in process efficiencies & achievement of pricing targets

Project management for a process this large is essential

It takes time to build trust with two different organizations

Executive buy-in from both organizations is key to success

Full physician alignment across the spine service line is key to driving standardization

Process mapping & problem solving may required an outside view

LESSONS LEARNED