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
ED
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
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