Transition to Value-Based CareHeart, Vascular, and Critical Care Surgical Services Baystate Medical Center
Springfield, MA
Consultant for Astute Medical, Zimmer-Biomet, and Edwards Lifesciences
What is the Problem?
Transitioning from a Volume-based to Value-based Payment System
Goal: improve quality, increase patient satisfaction and lower costs…the Triple Aim
Spending vs. Life Expectancy
IOM Report: $1B per year Spent on Unnecessary Healthcare
The Affordable Care Act • The Patient Protection and Affordable Care Act is a federal
statute signed into law by President Obama in 2010.
• In 2012, the United States Supreme Court upheld the constitutionality of the ACA's individual mandate as an exercise of Congress's taxing power.
• It was enacted to:
• increase the quality and affordability of health insurance.
• lower the uninsured rate by expanding public and private insurance coverage.
• reduce the costs of healthcare for individuals and the government.
It Succeeded in Lowering the Uninsured Rate
U.S. Secretary of Health and Human Services
Key Points: Health & Human Services Focus • Within 3 years 50% of Medicare payments to
physicians will be tied to an alternative payment model (ACO or bundled care)
• $800 Million provided to clinicians to encourage transition to alternative payment models to promote efficiency.
• Encourage coordination of care, reducing readmissions
• Emphasis on electronic health records (EHR's)
HHS Keypoint: Legalized Gainsharing
• Hospitals and physicians are generally paid separately for care provided in hospitals, creating misalignment between the incentives facing hospitals and those facing physicians.
• There are no direct financial gains to physicians (who often control the use of supplies and selection of devices which are paid for by the hospital) for providing more efficient care and decreasing hospital costs.
• Gainsharing is a contractual arrangement that sets up a formal reward system in which participants share in cost savings resulting directly from increased efficiency.
• Physicians participating in a gainsharing arrangement will have a financial stake in controlling hospital costs.
But what about the legal considerations?
• The Federal anti-kickback law prohibits any economic benefit in exchange for the referral of patients that will be reimbursed under any Federal health care program.
• Civil money penalty (CMP) prohibits hospital payments to a physician as an inducement to reduce or limit services to a Medicare patient.
• The Federal Stark law prohibits a physician from making referrals for health services if the physician has a “financial relationship” with a hospital.
• Office of the Inspector General acknowledged: “Properly structured, risk-sharing arrangements, that share cost savings can serve legitimate business and medical purposes.”
Waived
Accountable Care Act: Keypoint
Beginning in 2015, the Affordable Care Act, requires CMS to reduce hospital payments by 1% for the lowest-performing 25% with regard to Healthcare Aquired Conditions.
• Central Line Associated Bloodstream Infections (CLABSI)
• Catheter Associated Urinary Tract Infections (CAUTI)
• Mediastinitis
• DVT or infection after orthopedic surgery, bed sores, foreign object retained after surgery, air embolism, blood incompatibility, falls and injuries, iatrogenic pneumothorax
Alternative Payment Models (APM's)
• A Medicare APM can include:
• An ACO (accountable care organization) under the Medicare Shared Savings Program
• A model tested by CMS (bundle payments)
• Must use a certified EHR
• Must employ quality measures
What is Bundled Care? • Integrated financial model to
deliver improved quality and value for a defined set of services
• Reimbursement of hospitals/physicians based on the expected costs of a clinically defined episode of care.
• (Versus an ACO model which is focused on the care provided to an entire population of patients.)
Bundled Care
• Shares any money saved among the hospitals and providers.
The Challenges of Bundling
• An organizational structure must be in place that can accept the bundled payment and divide it in a way that the individual providers find acceptable.
• Hence, physicians participating in a bundled care program would be affected not only by their own costs but also the costs of related hospitalizations, diagnostic services, and post-acute care.
Centers for Medicare & Medicaid Services Innovation Center: BPCI (Bundled Payments
for Care Improvement Initiative) Model 2
• 61 Health Systems in the U.S. volunteered for this medicare CABG program beginning in 2014.
• Model 2 Bundle: Defines the episode of care to include the inpatient acute care and all related services up to 90 days post discharge.
• Includes all medicare isolated CABG patients (DRGs 231-236)
Centers for Medicare & Medicaid Services Innovation Center: BPCI (Bundled Payments
for Care Improvement Initiative) Model 2
•In exchange for gainsharing, hospitals/providers accept a 2% baseline decreased reimbursement.
•Hospitals/providers may opt to bear 100% risk up to the 75th, 95th, or 99th percentile national Episode payment.
Bundled Care Initiative: Keypoints
• The 2% discount applies to the total payment across all sites of care, meaning that the hospital is responsible for episode costs driven by physicians, SNF’s, and other post-acute providers.
• As a result, physician alignment and post-acute partnerships are critical to success. Hospitals must be closely aligned with high- quality, low-cost physicians and post-acute care providers.
• To qualify for the shared savings opportunity, you would have to beat quality performance targets on complications, readmissions, and the patient experience.
CABG Bundled Care (Model 2) Initiative Participants
Baseline (-2%) Medicare Part A Payments for Isolated CABG
Hospital accepts $800 - $1,600 less payment
• CABG (DRG 236)
How are these savings achieved? “In Administrator-Speak”
• Engage patients and families in the care
• Provide oversight of care coordination and quality monitoring working in partnership with case management and post-acute partnerships.
• Work to develop and ensure streamlined operations, patient satisfaction and care navigation.
• Develop best practice standards, transitions of care and regulatory rules, and requirements for post-acute care.
• Redesign care pathways, with savings and quality initiatives generalized to the whole patient population.
In the real world, it’s difficult to reduce cost while improving quality
• Decrease blood product utilization
• Reduce supply & pharmacy costs
• Reduce length of stay in the ICU/telemetry
(Cost/day ICU versus telemetry: $1600 versus $700)
• Reduce OR time ($12 per minute)
• Encourage “Fast Track”* Model
*Engelman RM, Rousou JA, Flack JE, et al: Fast-track recovery of the coronary bypass patient. Ann Thor Surg 1994; 58: 1742-6
Monthly Model of Care Dashboard
CABG Bundle All ISO-CABG’s
Monthly Model of Care Dashboard
Comparing Surgeons
HCAHPS as an Indicator for Patient Experience of Care
Local, regional, or national patient satisfaction data are now being reported via Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, also known as CAHPS® hospital survey)1
As part of the Affordable Care Act 2010, the Centers for Medicare and Medicaid (CMS) have established hospital reimbursement based on HCAHPS scores2
Started on October 1, 2012 Publicly available data Data delay: 6-9 months behind
1. US Department of Health and Human Services, Centers for Medicare and Medicaid. HCAHPS: Patients' Perspectives of Care Survey. http://cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed September 10, 2014. 2. American Hospital Association (AHA) Hospital-based purchasing program: the final rule. May 24, 2011. http://www.americangovernance.com/education/webinars/policy/pdf/final_rule_vbp_regulatory_advisory.pdf. Accessed September 10, 2014.
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Correlation of Pain Control and HCAHPS Components
Gupta A, Daigle S, Mojica J, Hurley RW. J Pain Res. 2009; 2: 157–164.
A high level of pain control is strongly correlated with HCAHPS patient care measures and global satisfaction
Patients who give high scores (9 or 10) to their pain treatment also scored other hospital HCAHPS components high
HCAHPS Component Coefficient of Correlation
Good communication with doctors 0.90
Good communication with nurses 0.92
Good communication about medicines 0.85
Good nursing service 0.81
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Myth #1 about “The Patient Experience”
“HCAHPS is only a hospital metric”
• Physicians with low patient satisfaction scores are more likely to be sued.
• Physician Quality Reporting System will base 2016 hospital reimbursement on this data.
• These metrics are available online and dictate referrals.
https://projects.propublica.org/s urgeons/
“Clinical coordination is not a real concern” Inpatient satisfaction correlates with:
• lower readmission rates.- Am J Managed Care
• lower inpatient mortality rates. - Circ
• decreased utilization of post acute services. - J Am Board of Fam Med
Myth #3 about “The Patient Experience”
“The nursing care drives the ratings; I don’t have any extra time for longer patient interactions”
• Physicians drive the patient experience.
• Simply knocking on the door and introducing oneself is the difference between a poor and excellent patient experience.
• The physician leads the collaboration, demonstrates leadership, patient empathy, and team building.
Readmissions
• Nationwide 18% (2 million) Medicare patients and 10% of all CABG patients are readmitted within 30 days of discharge.
• Cost to Medicare: $26 billion
• Up to 80% are preventable
• Average cost of readmission = $12,000
Readmission Penalties • Under the Affordable Care Act, hospitals are fined up to 3%
of their Medicare payments if too many Medicare patients return to the hospital within 30 days of discharge.
• In 2015, 2592 hospitals around the country were hit with readmissions penalties, which totaled $420 million.
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Avoiding Readmissions
• One of the key causes of patient readmission is infection.
• Critical care settings must double down on their attention to quality surrounding wound and pulmonary care, and appropriate antimicrobial stewardship.
• CV programs must be committed to minimizing variation in care standards, following care pathways, and enhancing clinical quality across the inpatient stay.
“Five Lessons Learned"
Baseline Medicare Part A Payments for Isolated CABG
• CATH + CABG: (DRG 234)
• The only difference is the MCC:
• New acute renal or respiratory failure, acute systolic/diastolic heart failure, shock, CVA, PE, sepsis, or STEMI.
• Hospital receive an extra $28,000 for accurate documentation of a major complication or comorbidity (MCC).
• Accurate acuity dictates expected morbidity and mortality.
Massachusetts Variations in Expected CABG Mortality
Utilize a Full-time Clinical Care Coordinator
• Hired an RN clinical care coordinator to specifically follow this cohort of patients.
• Provide pre-op education for patients regarding their discharge plans.
• Streamline transition of care and reduced LOS
• Provide a dedicated liaison to family
• Follow discharged patients (esp. with subtherapeutic INR's)
• Developed "Preferred Provider Network" of ECF's
Leverage Multidisciplinary Care
• At the core of a strong CICU, nurses specialized in critical care are essential to optimal performance.
• Checklists must be used during handoffs and transfers from the OR to the ICU to telemetry.
• In addition to nursing, including a pharmacist, dietician, physical therapist, and care manager on rounds, ensures adverse drug interactions are avoided, dietary concerns are managed, patient mobility is improved, and family members are informed of care progress.
• This results in improved care and increased value, as practitioners leverage common practices, while increasing adoption of evidence- based protocols.
IPOC (Interdisciplinary Plan of Care) Rounds
• Process of daily bedside rounds on all critical care and telemetry patients by an interdiscipliary team consisting of:
The MD, bedside RN, Unit RN Director, Case Manager, Care Coordinator, Physical therapist, Pharmacist, and Advance Practice Clinician (PA or NP)
• Review daily plan of care with the patient and family.
• Identify barriers for transition of care.
• Provide a written daily plan of care to the patient and the family.
IPOC Rounds
• Clinical coordinator follows-up by phone with patients at high risk for readmission.
• EMR automatically notifies us of all bundle patients entering the emergency room.
• Screen and audit all bundle readmissions.
• Utilize “observation status” to decrease readmission bundle cost and LOS.
Must Reduce Readmissions
Hospital-wide Strategies to Reduce Unnecessary ED Visits/Admissions
• Station an EDist (MD) and a Nurse Practitioner in the ER.
• Managers focus on high risk patients (e.g., COPD and CHF) with Care Coordinators as patient coaches.
• Follow guidelines for the outpatient management of previously admissible conditions (DVT, atrial fibrillation, cellulitis)
• Flag bundle patients presenting to the ED and track discharges/admissions in real time.
Patientping
Acute Inpatient Rehab
Our Efforts to Streamline the Post-acute Transition
• Patients and families counseled about going home preoperatively.
• Some patients may not benefit from a visiting nurse.
• The preferred provider network needs to be strengthened.
• An extra day or two in the hospital may be better for the patient then being discharged to a skilled nursing facility/inpatient rehab.
• Patients can be discharged earlier if the outpatient Coumadin testing, reporting, and prescribing is more streamlined.
• Coumadin clinic hours on nights and weekends are being adjusted.
Our Next Steps • Mandate "best practice" models, discourage unnecessary tests,
transfusions, procedures, and consults.
• Encourage discharge and readmission of preop patients after cath on anti-platelet agents to reduce unnecessary lengths of stay.
• Track all post-acute bundle patients discharged to SNF's.
• Share profits/loss bundle dollars with rehabs and SNF's.
• Base physician reimbursement on quality and cost rather than RVUs.
• We now have five active bundle projects with more in the works.
How popular has the Bundled Payments for Care Improvement Initiative Model 2 become?
Bundled Payment Programs Are Here to Stay
• Lowe’s covers the full cost of surgery, as well as travel and lodging for a worker and a relative.
• The company health plan will not cover thousands of dollars of unbundled costs at local hospitals.
Conclusions
• We must be prepared for the widespread adoption and transparency of alternative payment models.
• I have tried to provide a framework for the operational components and challenges inherent in a CABG bundled care financial risk arrangement.
• Improving outcomes while simultaneously decreasing cost (providing greater value) is not easy.
• I believe the key to success in this bundle revolves around the close collaboration within a Multi-Disciplinary Team.
Questions?
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The Affordable Care Act
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HHS Keypoint: Legalized Gainsharing
Accountable Care Act: Keypoint
Centers for Medicare & Medicaid Services Innovation Center: BPCI (Bundled Payments for Care Improvement Initiative) Model 2
Centers for Medicare & Medicaid Services Innovation Center: BPCI (Bundled Payments for Care Improvement Initiative) Model 2
Bundled Care Initiative: Keypoints
Baseline (-2%) Medicare Part A Payments for Isolated CABG
How are these savings achieved? “In Administrator-Speak”
In the real world, it’s difficult to reduce cost while improving quality
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Correlation of Pain Control and HCAHPS Components
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Readmissions
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Leverage Multidisciplinary Care
IPOC Rounds
Patientping
Our Next Steps
How popular has the Bundled Payments for Care Improvement Initiative Model 2 become?
Bundled Payment Programs Are Here to Stay
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