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 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) 2

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 Trigger Rules Standard Care Pathway Inclusions/Exclusions Duration Cardiologist Imaging - MRI Orthopod Take-home PCP Supplies Pharmacy Orthopod Pharmacy PCP Cardiologist Cardiologist Pre-op Lab Pharmacy Orthopod Pharmacy PCP PCP Orthopod PT PT Facility Facility Episode Of Care 1 month Pre-op Surgery Date Readmission 1 month 3 month /Reoperation Post-Op Post-Op Diagnostic Triggering Event Follow-up Care 5

Alternative Payment Methodologies • 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 6

Hip and Knees Shared Savings Initiative: Program Overview • 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 7

Quality Criteria Professional & Operating Ancillary Room Supply Services Costs Physician Physician COST CLAIMS Savings Savings Operating Room Supply Costs Professional & Ancillary Quality Services Threshold • Savings reduce Health Plan • Savings shared between Health (80 points) payment to hospital Plan and physician • Savings shared between hospital • Based on evidence-based clinical and physician pathway • Based on best practice • Includes 30 days pre and 90 days post-surgery  All costs of episode of care, except DRG Physician • Bundled Payments only apply to Shared Savings elective procedures acuities 1&2 Payment 8

Hip and Knees Shared Savings Initiative: Physician Scorecard – Quality (7/1/2013 – 10/31/2013) Hips and Knees Shared Savings Initiative Physician Scorecard - Quality SAMPLE Period: 7/1/2013 - 10/31/2013 3 Total Surgeries By Physician: Goal Maximum Measure Eligible Surgeries Score (Threshold) Potential Points Meets Goals? Adherence to Pathway: Order Sets 3 100.0% > 60.0% 25 Yes 0 Blood Utilization 0.0% < 10.0% 5 Yes 3 Surgical Site Infections 0.0% < 1.0% 10 Yes 3 90-Day Readmission* 0.0% < 1.0% 10 Incomplete 3 Pulmonary Embolism 0.0% = 0.% 5 Yes 1 Patient Satisfaction 100.0% >= 75% 10 Incomplete Eligible Surveys Surgeries Returned Pre-Surgical 3 2 N/A, no post-surgical 5 Pt Quality of Life (SF12) 10 Incomplete follow-up Improvement Post-Surgical 3 0 Pre-Surgical 3 3 Functional Assessment Patients do not show Any 25 Incomplete (Physical Therapy evaluation) overall improvement Improvement Post-Surgical 3 2 The quality scores must be at or above 80/100 by year end reconciliation in order for physicians to be eligible to receive savings. 9

Hips and Knees Shared Savings Initiative: Key Metrics Hip Replacements Hip Replacements Commercial Medicare Commercial Medicare Surgeries Surgeries Avg. # Avg. # Avg. # Avg. # Avg. $ Avg. $ Avg. $ Avg. $ of of of of per Case per Case per Case per Case Pre-Surgical Testing Tests Tests Inpatient Stay Consults Consults Lab Specialty Consults CBC with Initial Platelets Follow PCP Consult Up PT-INR Selected Key Initial BMP impactable areas Follow Pain Service Up UA and C&S Initial MRSA Culture Follow Cardiology Up All Other Total Total Avg. # Avg. # Radiology Avg. $ Avg. $ of of Hip Unilateral per Case per Case Post-Surgical Rehab* Visits Visits 1 View Physical Therapy Hip Unilateral Complete Selected Key Minimum 2 Views impactable areas Home Health (Nurse) Hips Bilateral 2 Views Anteropost Pelvis Chest, 2 Views, Frontal & Home PT Lateral EKG Outpatient PT All Other Total Total 10

Target OR Supplies, Pharmacy, and Blood Cost Physical Therapy Labs OR cost distributions provided for example/reference purposes only Radiology Room and Board Hips Target Costs: Implant Anesthesia Blade Catheter Pharmacy Drain Nursing Staff Dressing Pharmacy Blood Blood OR Costs PA’s Products Knees Target Costs: OR and Implant Equipment Additional Implant OR Components Usage Blade Supplies* Catheter Recovery Cement Pharmacy Blood *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 .

Claims Cost per Episode and OR Supply Costs Maximum 75 th Percentile Average Median 25 th Percentile Minimum 12

Hip and Knee Shared Savings Pilot Update 13

UPMC Value Based Payment Timeline Hip/Knee & Low Risk Delivery Hip/Knee Shared Savings Prospective Bundled Payments • Time Frame •July 2013 – July 2014 • Time Frame •July 2014 – July 2015 •July 2015 – July 2016 • Model • Model •Retrospective Reconciliation of Claims •Single bundled payment for entire •Acuities 1 and 2 only continuum of care July January July 2013 2015 2015 Spine Shared Savings 1. Further implementation of AVER Bundled • Time Frame •January 2015 – 2016 Payment Software • Model 2. Contracting with •Retrospective Reconciliation of Claims external providers •Separate bundles for lumbar and 3. Other potential bundles cervical fusion 1. COPD 2. Hysterectomy 3. CHF 4. CAD 5. AMI 14

Questions? Stephen Perkins MD Vice President, Medical Affairs Tom Aubel Director of Medical Payment Strategy & Policy 15

Presenters have nothing to disclose ACHP A FFORDABILITY W EBINAR L OW R ISK C ARDIAC P ROTOCOLS : R EDUCING C OST & I MPROVING C ARE December 17, 2014 Gretchen Leiterman William Nelson, MD, PhD Vice President, Operations & Department Head – HealthPartners CV Service Line Hospital Specialty Services Medical Director, Regions Hospital Heart Center

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