ACHP Affordability Discussion Specific Cost Savings Strategies - - PowerPoint PPT Presentation

ACHP Affordability Discussion

Specific Cost Savings Strategies

December 17, 2014

ACHP News and Upcoming Events

2 Recent Affordability Profiles:

• Asthma Home Visiting and Case

Management program (UCare)

• Behavioral Health Case

Management (CDPHP)

• Low-Risk Chest Pain Protocol

(HealthPartners)

• Reduced Blood Utilization (Select

Health)

• Heart Failure Clinic (Security

Health Plan)

• Care Partners for Frail Elders

(Independent Health)

• Use of Clinical Pharmacists (GHC-

SCW)

• Shared Decision-Making (Group

Health)

• Improved PAC and SNF

Performance (Geisinger Health Plan)

Specific Cost Savings Strategies

Payment Reform Models:

• Stephen Perkins, M.D., Vice President, Medical Affairs

UPMC Health Plan

Improved Clinical Efficiency:

• Gretchen Leiterman, Vice President, Operations and

Hospital Specialty Services, HealthPartners

• William Nelson, M.D., Ph.D., Department Head,

HealthPartners Cardiology and Medical Director, Regions Hospital Heart Center

3

Value Based Payment Initiatives Knee and Hip Replacement Bundled Payment Model ACHP Webinar 12/17/2014

Bundled Payments Episode Consist of many moving parts

Payment negotiation, allocation, billing, claims adjudication, reconciliation

Episode Of Care

Trigger Rules Standard Care Pathway Inclusions/Exclusions Duration

1 month Pre-op Surgery Date Readmission /Reoperation 1 month Post-Op 3 month Post-Op

Diagnostic Triggering Event Follow-up Care

PCP Orthopod Imaging - MRI Cardiologist

Facility

Pre-op Lab

Orthopod

PCP Cardiologist Pharmacy Take-home Supplies PT

Facility

Pharmacy Orthopod PCP PT Orthopod Pharmacy Cardiologist PCP Pharmacy

5

Alternative Payment Methodologies

6

• Objective - Incentivize physicians to deliver quality care across the entire

episode of care in a cost-efficient manner

• Four examples of potential payment models:
• 1. Shared Savings (Retrospective Reconciliation)
• 2. Retrospective Bundled Payment
• 3. Prospective Bundled Payment
• 4. Global Capitation
• All payment methodologies are subject to quality and clinical pathway-

adherence standards in order to receive any incentive payments

• Considerations when determining the appropriate payment model

– Definition of continuum of care / pathway – Participation / buy-in from providers – Quality benchmarks / standards – Utilization benchmarks / standards

• Program Objective:
• Incentivize physicians to increase quality of care by:

1. Adhering to an evidence-based pathway, and 2. Choosing the most cost effective implantable devices and supplies

• Program Criteria:
• Pilot period effective from July 2013 to July 2014
• UPMC Health Plan is the patient’s primary insurer
• Patient is a Commercial Fully Insured/ASO or Medicare member
• Patient is receiving a total hip/knee replacement (MS DRG 469 & 470)
• Acuity Level 1 and 2 only as determined by APR DRG
• Patient is discharged to home

Hip and Knees Shared Savings Initiative: Program Overview

7

Professional & Ancillary Services Operating Room Supply Costs

Physician CLAIMS Savings Physician COST Savings Quality Threshold (80 points)

Physician Shared Savings Payment Professional & Ancillary Services

• Savings shared between Health

Plan and physician

• Based on evidence-based clinical

pathway

• Includes 30 days pre and 90 days

post-surgery  All costs of episode of care, except DRG

• Bundled Payments only apply to

elective procedures acuities 1&2

Operating Room Supply Costs

• Savings reduce Health Plan

payment to hospital

• Savings shared between hospital

and physician

• Based on best practice

Quality Criteria

8

Hip and Knees Shared Savings Initiative: Physician Scorecard – Quality (7/1/2013 – 10/31/2013)

9 Total Surgeries By Physician: 3 Score Goal (Threshold) Maximum Potential Points Meets Goals? 100.0% > 60.0% 25 Yes 0.0% < 10.0% 5 Yes 0.0% < 1.0% 10 Yes 0.0% < 1.0% 10 Incomplete 0.0% = 0.% 5 Yes 100.0% >= 75% 10 Incomplete Eligible Surgeries Surveys Returned Pre-Surgical 3 2 Post-Surgical 3 Pre-Surgical 3 3 Post-Surgical 3 2 25 10 5 Pt Improvement Incomplete 3 1 Quality of Life (SF12) Functional Assessment (Physical Therapy evaluation) N/A, no post-surgical follow-up Patients do not show

• verall improvement

Patient Satisfaction Eligible Surgeries 3 3 3

Hips and Knees Shared Savings Initiative

Physician Scorecard - Quality

SAMPLE

Period: 7/1/2013 - 10/31/2013 Adherence to Pathway: Order Sets Blood Utilization Surgical Site Infections 90-Day Readmission* Pulmonary Embolism Any Improvement Incomplete Measure

The quality scores must be at or above 80/100 by year end reconciliation in order for physicians to be eligible to receive savings.

Hips and Knees Shared Savings Initiative: Key Metrics

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• Avg. #
• f

Tests

• Avg. $

per Case

• Avg. #
• f

Tests

• Avg. $

per Case CBC with Platelets PT-INR BMP UA and C&S MRSA Culture All Other Total Hip Unilateral 1 View EKG All Other Total Chest, 2 Views, Frontal & Lateral Hips Bilateral 2 Views Anteropost Pelvis Hip Unilateral Complete Minimum 2 Views Pre-Surgical Testing Lab Radiology Hip Replacements Commercial Medicare Surgeries

Selected Key impactable areas

• Avg. #
• f

Consults

• Avg. $

per Case

• Avg. #
• f

Consults

• Avg. $

per Case PCP Consult Initial Follow Up Pain Service Initial Follow Up Cardiology Initial Follow Up Total

• Avg. #
• f

Visits

• Avg. $

per Case

• Avg. #
• f

Visits

• Avg. $

per Case Home Health (Nurse) Home PT Outpatient PT Total Inpatient Stay Specialty Consults Post-Surgical Rehab* Physical Therapy Hip Replacements Commercial Medicare Surgeries

Selected Key impactable areas

OR Costs

Labs Radiology Nursing Staff Anesthesia Room and Board Recovery PA’s OR and Equipment Usage

OR Supplies* Pharmacy Blood Products

Physical Therapy Hips Target Costs:

Implant Blade Catheter Drain Dressing Pharmacy Blood

Knees Target Costs: Implant

Additional Implant Components Blade Catheter Cement Pharmacy Blood

Target OR Supplies, Pharmacy, and Blood Cost

*OR Supply costs are based on FY2012 supply items charged to patients. They do not include low-cost items such as sutures, drapes, gloves and reusable instruments. They also do not include any supplies used but not documented in Surginet. OR cost distributions provided for example/reference purposes only

Claims Cost per Episode and OR Supply Costs

12

Maximum 75th Percentile Average Median 25th Percentile Minimum

Hip and Knee Shared Savings Pilot Update

13

UPMC Value Based Payment Timeline

14 Hip/Knee Shared Savings

• Time Frame
• July 2013 – July 2014
• July 2014 – July 2015
• Model
• Retrospective Reconciliation of Claims
• Acuities 1 and 2 only

Spine Shared Savings

• Time Frame
• January 2015 – 2016
• Model
• Retrospective Reconciliation of Claims
• Separate bundles for lumbar and

cervical fusion

Hip/Knee & Low Risk Delivery Prospective Bundled Payments

• Time Frame
• July 2015 – July 2016
• Model
• Single bundled payment for entire

continuum of care

July 2013 January 2015 July 2015 1. Further implementation

• f AVER Bundled

Payment Software 2. Contracting with external providers 3. Other potential bundles 1. COPD 2. Hysterectomy 3. CHF 4. CAD 5. AMI

Questions?

Stephen Perkins MD Vice President, Medical Affairs Tom Aubel Director of Medical Payment Strategy & Policy

15

ACHP AFFORDABILITY WEBINAR LOW RISK CARDIAC PROTOCOLS: REDUCING COST & I MPROVING CARE

December 17, 2014

Gretchen Leiterman Vice President, Operations & Hospital Specialty Services William Nelson, MD, PhD Department Head – HealthPartners CV Service Line Medical Director, Regions Hospital Heart Center

Presenters have nothing to disclose

Affordability Profile: Improving low risk cardiac care

• Organizational Overview
• Triple Aim Results
• Low Risk Chest Pain Protocol
• Next Steps

– Low Risk Congestive Heart Failure Protocol – Low Risk Atrial Fibrillation Protocol

HealthPartners

• Not-for-profit, consumer-governed
• Integrated care and financing system

– A team of 21,000 people – Health plan

• 1.4 million health and dental members in Minnesota and surrounding states

– Medical Clinics

• 1 million patients
• 1,700 physicians

– Park Nicollet Health Services – HealthPartners Medical Group – Stillwater Medical Group

• 55 medical and surgical specialties
• 45 primary care clinics
• Multi-payer

– Dental Clinics

• 60 dentists, 21 locations

– Seven hospitals

• Regions: 454-bed level 1 trauma and tertiary center
• Methodist: 426-bed acute care hospital, featuring the Jane Brattain Breast Center
• Lakeview: 97-bed acute care hospital, national leader in orthopedic care
• Hudson: 25-bed critical access hospital, award-winning healing arts program
• Westfields: 25-bed critical access hospital, regional cancer care location
• St. Francis: 86-bed community hospital (partial owner)
• Amery: 25-bed critical access hospital, joining HealthPartners January 1, 2014

E le c tr

• nic Me dic a l R

e c or ds

• Na me d “Mo st Wire d” b y Ho spital and

He alth Ne two rks ma g a zine fo ur ye a rs in a ro w

Community be ne fit

• 2013 Anti-Stig ma Awa rd fro m Minne so ta

Na tio na l Allia nc e o n Me nta l Illne ss

• Re c o g nize d a s a ‘ L

e a de r in L GBT He a lthc a re E q ua lity’ b y the Huma n Rig hts Ca mpa ig n

T

• p Hospita l
• L

e a pfro g T

• p Ho spita l, the mo st

c o mpe titive ho spita l q ua lity a wa rd in the c o untry.

• Only urb a n ho spita l in Minne so ta to

e a rn this re c o g nitio n

• Awa rde d “Gra de A” in T

he L e a pfro g Gro up Ho spita l Sa fe ty Sc o re .

Minne sota Hospita l Assoc ia tion

• Sa fe fro m F

a lls, Sa fe Skin, Sa fe Site , Sa fe Co unt, Sa fe Ac c o unt

• Re c o g nize d b y MHA a nd the Ma rc h o f Dime s

fo r re duc ing e a rly e le c tive de live rie s

• Re c ipie nt o f 2013 Go o d Ca tc h Awa rd fo r

pa tie nt sa fe ty

Joint Commission

• One o f the to p pe rfo rming ho spita ls in the

na tio n fo r he a rt a tta c k, he a rt fa ilure , pne umo nia a nd surg ic a l c a re

• F

irst ho spita l in Minne so ta to b e na me d a Ce rtifie d Co mpre he nsive Stro ke Ce nte r

Cr itic a l Ca r e

• In 2013, the Ame ric a n Asso c ia tio n o f Critic a l-

Ca re Nurse s (ACCN) ho no re d Re g io ns SICU with its Be a c o n Awa rd fo r E xc e lle nc e

• Re g io ns inpa tie nt he a rt a nd va sc ula r unit

re c e ive d the sa me a wa rd in 2010 a nd 2012

E nvir

• nme nta l e xc e lle nc e
• Re c e ive d a wa rd fro m Pra c tic e

Gre e nhe a lth fo r a c hie ving b e nc hma rks in e ne rg y c o nse rva tio n, me rc ury re duc tio n po llutio n pre ve ntio n a nd re c yc ling

Disting uishe d Hospita l for Clinic a l E xc e lle nc e

• Amo ng He a lthGra de s to p 5 pe rc e nt o f ho spita ls

in the na tio n fo r hig h-q ua lity o utc o me s

• Amo ng “Ame ric a ’ s 100 Be st Ho spita ls” fo r

pulmo na ry c a re , stro ke c a re a nd c ritic a l c a re

Regions Hospital & HealthPartners – Collaborating to improve quality, experience & cost

Results: Leapfrog Group - Quality and Resource Use Regions Hospital

Results: HealthPartners – Heart Attack (AMI) Regions Hospital

0.70 0.75 0.80 0.85 0.90 0.95 1.00 80% 85% 90% 95% 100% 2005 2006 2007 2008 2009 2010 2011 2012 2013

0.84 AMI Core Measure Bundle Includes*

• Aspirin at Arrival and Discharge
• ACE1 or ARB for LVSD
• Smoking Cessation Counseling

DECREASE Total Cost Index (compared to statewide average). Less than 1 is better than network average INCREASE percentage of patients who “Would Recommend” Regions Hospital

94% Core Measure Outcomes 81% Patient Satisfaction Total Cost of Care 96% 100%

Low Risk Chest Pain

Low Risk Chest Pain Protocol - Background

• Implemented in September 2011
• Collaboration between Cardiology, Emergency

Medicine and Hospital Medicine

• Aim: Standardize care for Low Risk Chest Pain

patients to improve the patient experience, ensure safety (using evidence to guide treatment), and reduce costs to the system

• Three years of consistent performance and

positive outcomes

Innovation: HealthPartners Low Risk Chest Pain Program Flow @ Regions Hospital

Typica cal US Pat ient Experience ce: ER evaluation hospital observation admit 1-2 day stay (often includes noninvasive imaging) home Heal alt hPar art ners Low

• w Risk Chest Pai

ain Prot

• t oc
• col
• l:

Rapid ER evaluation

• TIMI Risk score – 0,1
• Negative troponin at 0 and 6 hours

Low risk group (most) home stress test next day (echo/nuclear, 7d/wk)

$2600 savings per patient

Chest Pain - Volume Trend (2007-2014) Regions Hospital Growth

409 475 474 387 205 115 49 86 456 593 762 921 1,028 826 843 868 126 658 690 662

865 1,068 1,236 1,308 1,359 1,599 1,582 1,616

200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 2007 2008 2009 2010 2011 2012 2013 2014 YTD Annualized Inpatient Observation LRCP

2008-2010, Medicare

2008 2010 PCI ICD Implant

16% 21% 27% 36%

Length of Stay for Common CV Cases

Condition/ Procedure 1-Day LOS 1 or 2-Day LOS AMI 17% 34% Chest Pain 40% 67% Arrhythmia2 25% 49% Carotid Stent 61% 75% CEA3 56% 74% Heart Failure 9% 27% Hypertension 32% 60% ICD Implant4 31% 41% PCI 30% 54% PVI5 20% 34%

Percent of Cases Performed Outpatient1

Innovation: HealthPartners Low Risk Chest Pain Outcomes @ Regions Hospital

10 20 30 40 50 60 70 80 90

ED Low risk chest pain patients

OP Scheduled Eve & Weekends No Show Positive Stress-Cath ED Pt stress Mon - Fri 8 am - 5 pm Monthly Totals

OP Scheduled Eve & Weekends No Show Positive Stress-Cath ED Pt stress Mon - Fri 8 am - 5 pm Totals 2025 481 29 121

Chest Pain – Readmissions Decline Regions Hospital

24 18 13 7

5 10 15 20 25 30 2010 2011 2012 2013 Readmissions

Low Risk Chest Pain Protocol - Success

• More than 2000 patients have benefited at

Regions Hospital alone

• Safely avoided unnecessary care and

benefited organization by $4 million dollars in rate alone

• HealthPartners shares these protocol with
• ther participating providers to spread the

benefits across the network

• Success of this program led to exploration of
• ther low risk cardiac pathways

Low Risk Congestive Heart Failure

Low Risk CHF Protocol - Background

• AIM: create protocol to safely avoid

hospitalizations/readmissions for low risk CHF patients through team approach involving ED, hospital medicine, and cardiology

• Hospital readmissions for CHF have historically

been approximately 20%

– Affordable care act institutes penalties for CHF readmissions

Innovation: HealthPartners Low Risk Heart Failure Program Flow @ Regions Hospital

ED Presentation Home Observation Meets low risk criteria

IV Diuretics ED Observation No

Yes

Next day CHF Clinic follow-up 1 week CHF Clinic Follow-up

Innovation: HealthPartners Low Risk Heart Failure Protocol Regions Emergency Department

Innovation: HealthPartners Low Risk Heart Failure Outcomes @ Regions Hospital

Protocol initiated in June 2012 and has led to change in ED care patterns

• ED trends from 2010 onward demonstrates a trend in higher

utilization of observation and discharges to home after this protocol was initiated In 7 month period, 13 total 30-day inpatient admissions were saved

• 4 total 30-day inpatient admissions were saved by placing

patients in observation

• 9 total 30-day inpatient admissions were saved by discharging

patients to home Overall, this is a low risk population

• Only 7 of 59 patients were readmitted within 30 days

Heart Failure Volumes:

Shift from Inpatient to Observation & Low-Risk Treatment

474 451 460 515 62 123 119 16 100% 88% 79% 79% 21% 18% 20.25% 20.62% 18.70% 18.65% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 100 200 300 400 500 600 700 Cases

Inpatient Observation Low Risk Heart Failure % Inpatient % Observation % Low Risk Heart Failure % Readmissions

2011 2012 2013 2014 YTD Annualized 2% 12%

Low Risk Atrial Fibrillation

Low Risk Afib Protocol - Background

• 2.6 million people in US 2010
• Prevalence projected to double 2020
• Afib accounts for 1% of all ED visits in US

65% result in hospital admission 20% 30 day adverse outcome

• ED management varies greatly – proclivity for

cardioversion in patient with recent onset afib

• Spontaneous conversion to NSR in 70% patients

with recent onset afib.

Innovation: HealthPartners Low Risk Afib Program Flow @ Regions Hospital

After Visit Summary

• Echo will be done next day at 10am
• Cardiology visit at 11:20am
• NPO after 7am except meds
• You may need a ride home

Atrial Fibrillation Volumes:

Shift from inpatient to observation

213 207 196 180 43 53 78 52 16 83% 80% 72% 73% 17% 20% 28% 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 50 100 150 200 250 300 350 400 C a s e s

Inpatient Observation Low Risk Afibrillation % Inpatient % Outpatient % Low Risk Afibrillation

2011 2012 2013 2014 YTD Annualized 6%

Affordability Profile: Improving low risk cardiac care Summary of Success

• Reduced the number and rate of readmissions

for chest pain & congestive heart failure patients

• Improved the experience of care for low risk

cardiac patients

• Reduced the costs to patients and the system
• verall
• Shared learnings and benefits across all

HealthPartners Networks

Questions & Discussion

Discussion

• What type of cost-reduction information from ACHP

would be of the greatest value to you in 2015?

• What are new, ongoing or particularly innovative cost-

reduction initiatives taking place at your plan?

• How are cost reduction strategies different for plan-

employed versus network physicians?

• How do your approaches either differ or align with those
• f UPMC and HealthPartners?

44

mfuentes@achp.org Phone: 202-785-2247 www.achp.org 1825 Eye Street, NW Suite 401 Washington, DC 20006