ECLS Program Finances Financial Implications Julie Parrish, MBA - - PowerPoint PPT Presentation

ECLS Program Finances – Financial Implications

Julie Parrish, MBA Business Partner Director Jonathan Delap, BS Business Partner Senior Specialist University of Kentucky

Faculty Disclosure

• Nothing to disclose

A major practice gap exists in the availability of ECLS programs. Individual hospitals must determine the need for an ECLS program in their area and obtain institutional commitment prior to program

• development. Financial drivers of a program will include equipment

and personnel costs compared to the volume and outcomes of patients.

Educational Need/Practice Gap

Upon completion of this educational activity, you will be able to:

• 1. Discuss the financial impact of the ECLS program on the
• rganization
• 2. Discuss considerations and factors in reviewing financial

performance for program sustainability

Objectives

The desired change/result in practice is to be able to evaluate how an ECLS program fits into their institution and balance growth potential against the cost of building a sustainable program. In addition, participants will be aware of the changing paradigm in health care payments.

Expected Outcome

• What stage is your program in?
• Planning, infant, established, growing?
• Ongoing Topics
• Identify Goals of the Program
• Right size the program
• Equipment and staff to meet Goals

Understanding w here you are currently

• Revenue
• Increase in charges due to extensive resources used
• Increase in revenue due to shift in MS DRG
• More to be discussed
• Internal review
• Professional Coding and RVU Production

Financial Impact on the Hospital

Chart Source:

Medicare MS DRG 003 Only (Does include non ECMO cases) From Medicare Provider Utilization and Payment Data for FY 2016

ECLS Program Impact on Hospital - Revenue

Provider State Provider Name Provider City Total Discharges Avg Covered Charges Avg Medicare Payments UNIVERSITY OF KENTUCKY HOSPITAL LEXINGTON 89 504,957 $ 137,525 $ UNIVERSITY OF LOUISVILLE HOSPITAL LOUISVILLE 41 570,812 $ 111,143 $ NORTON HOSPITAL / NORTON HEALTHCARE PAVILION LOUISVILLE 38 322,693 $ 86,818 $ JEWISH HOSPITAL & ST MARY'S HEALTHCARE LOUISVILLE 28 504,613 $ 124,101 $ PIKEVILLE MEDICAL CENTER PIKEVILLE 21 591,433 $ 136,820 $ SAINT JOSEPH HOSPITAL LEXINGTON 19 328,000 $ 110,302 $ BAPTIST HEALTH LOUISVILLE LOUISVILLE 11 375,835 $ 76,741 $ INDIANA UNIVERSITY HEALTH INDIANAPOLIS 91 563,477 $ 132,613 $ ST VINCENT HOSPITAL & HEALTH SERVICES INDIANAPOLIS 42 408,519 $ 101,431 $ LUTHERAN HOSPITAL OF INDIANA FORT WAYNE 27 534,250 $ 89,702 $ FRANCISCAN HEALTH INDIANAPOLIS INDIANAPOLIS 26 408,149 $ 110,482 $ MEMORIAL HOSPITAL OF SOUTH BEND SOUTH BEND 20 408,515 $ 103,710 $ PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE 17 494,023 $ 124,136 $ ESKENAZI HEALTH INDIANAPOLIS 13 564,694 $ 177,526 $ DEACONESS HOSPITAL INC EVANSVILLE 12 279,605 $ 80,945 $ CLEVELAND CLINIC CLEVELAND 89 635,272 $ 137,076 $ OHIO STATE UNIVERSITY HOSPITALS COLUMBUS 65 637,006 $ 133,128 $ UNIVERSITY OF CINCINNATI MEDICAL CENTER, LLC CINCINNATI 51 566,623 $ 127,340 $ RIVERSIDE METHODIST HOSPITAL COLUMBUS 35 372,482 $ 86,136 $ TOLEDO HOSPITAL THE TOLEDO 33 455,129 $ 88,770 $ MOUNT CARMEL WEST COLUMBUS 32 270,923 $ 84,593 $ UH CLEVELAND MEDICAL CENTER CLEVELAND 30 487,108 $ 128,907 $ GRANT MEDICAL CENTER COLUMBUS 23 431,334 $ 105,679 $ KETTERING MEDICAL CENTER KETTERING 23 409,636 $ 88,070 $ ST ELIZABETH YOUNGSTOWN HOSPITAL YOUNGSTOWN 23 283,618 $ 71,702 $ SUMMA HEALTH SYSTEM AKRON 20 610,103 $ 75,219 $ MERCY ST VINCENT MEDICAL CENTER TOLEDO 20 643,898 $ 102,906 $ MIAMI VALLEY HOSPITAL DAYTON 17 375,766 $ 81,084 $ METROHEALTH SYSTEM CLEVELAND 15 301,581 $ 123,332 $ MERCY MEDICAL CENTER CANTON 14 162,696 $ 87,646 $ CHRIST HOSPITAL CINCINNATI 14 567,230 $ 131,590 $ AKRON GENERAL MEDICAL CENTER AKRON 12 386,053 $ 68,797 $ AULTMAN HOSPITAL CANTON 12 202,001 $ 74,975 $ UNIVERSITY OF TOLEDO MEDICAL CENTER TOLEDO 11 539,643 $ 158,166 $ CHARLESTON AREA MEDICAL CENTER CHARLESTON 29 244,189 $ 81,925 $ WEST VIRGINIA UNIVERSITY HOSPITALS MORGANTOWN 23 351,199 $ 124,736 $ CABELL HUNTINGTON HOSPITAL INC HUNTINGTON 11 421,339 $ 116,975 $ WV OH IN KY

Department Roll Up 2016 2017 2018 CV ICU Bed and Floor Charges 22.05% 17.90% 20.35% Pharmacy 15.85% 14.39% 18.92% Operating Room 13.66% 12.06% 8.76% Respiratory 10.19% 10.22% 12.04% ECMO Charges 7.63% 9.70% 8.37% Lab Charges 4.75% 5.09% 5.96% Blood 4.01% 3.26% 2.90% Organ Charges 2.43% 3.03% 3.80% Cath Lab 1.94% 3.82% 3.36% Miscellaneous Supplies 2.37% 2.88% 1.87% CV Acute Care Bed and Floor Charges 1.89% 2.31% 2.79% Trauma ICU Bed and Floor Charges 1.23% 4.70% 0.79% Medical ICU Bed and Floor Charges 1.97% 1.81% 2.47% Diagnostic Radiology 1.43% 1.70% 1.55% Other Miscellaneous Departments 1.86% 1.21% 1.13% Anesthesia 1.92% 1.57% 0.51% Other Bed and Nursing Floor Charges 1.18% 1.09% 1.29% Physical and Speech Therapy 0.83% 1.07% 1.27% Dialysis 0.94% 1.21% 0.79% Interventional Services 0.20% 0.24% 0.68% KCH ICU Bed and Floor Charges 1.18% 0.00% 0.01% Trauma Acute Bed and Floor Charges 0.20% 0.49% 0.18% CV Diagnostic Services 0.21% 0.22% 0.19% Laboratory 0.09% 0.03% 0.03%

ECLS Program Impact on Hospital – Charges During Stay

ECMO Length of Stay Analysis

10

• Length of stay is down by
• ver two days but length of

runs are up by 0.42 days.

• Large variance remains in

pre and post ECMO stays

Length of Stay Data FY 2016 FY 2017 Variance % Change Cases 36 42 6.00 17% Length of Stay 28.39 24.57

• 3.82
• 13%

Length of Run 8.06 8.48 0.42 5% Pre Run Stay 3.19 10.14 6.95 218% Post Run Stay 18.03 6.79 (11.24)

• 62%

ICU 18.89 16.64 (2.25)

• 12%

Telemetry 2.53 1.55 (0.98)

• 39%

Progressive 4.78 1.60 (3.18)

• 67%

Acute 2.19 4.79 2.59 118% Fiscal Year Data

Other Statistical Categories

• 36% FYTD 2017 (ended at 41% for

full FY)

• 64% FYTD 2018

11

Mortalities Cannulation Mode

Payor Mix Discharge MS DRG

24% 33% 40% 43%

36% 18% 0% 5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2018 2017 Managed Care Medicare Medicaid Govt / Other Self-Pay / Charity

Discharge MS DRG FY 2016 FY 2017 FY 2018 001 - Heart Transplant or VAD 10 10 4 003 - ECMO or Trach 81 71 37 235 - CABG W/O Cath w/ MCC

• 1
• 769 - POSTPARTUM POST ABORTION

DIAGNOSES W O.R. PROCEDURE

• 1

We have submitted the case under MS DRG 769 to coding compliance

Cannulation Mode FY 2016 FY 2017 FY 2018 VA 50 39 22 VA - VV 2 3

• VV

39 40 20

Questions Next Steps

• Costs
• Pharmaceutical Costs
• Costs associated with Pre Run, ECMO Run and Post Run?
• Are all costs to the program allocated correctly with correct cost center

being used?

• Review of Patients
• Identify cases in which ECMO

would have benefited patient

• Patients with a diagnosis from

the list on the right

• Discharge Status of Expired
• Adjust for non-ECMO

candidates due to comorbidities

• What DRGs are these

currently being discharged under?

Diagnosis to Review

• Acute Respiratory Failure
• Acute Respiratory Distress

Syndrome

• Chronic Respiratory Failure
• Acute and Chronic Respiratory

Failure

• Cystic Fibrosis with Pulmonary

Manifestations

• Idiopathic Pulmonary Fibrosis
• Pulmonary Hypertension
• Pulmonary Embolism
• Cardiogenic Shock

Identifying Missed Opportunities

Professional Maintenance of ECMO

Category CPT Description RVUs 33946 Initiation, veno-venous 6.00 33947 Initiation, veno-arterial 6.63 33951 Insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age 8.15 33952 Insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older 8.15 33953 Insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age 9.11 33954 Insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older 9.11 33948 Daily management, each day, veno-venous 4.73 33949 Daily management, each day, veno-arterial 4.60 33957 Reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age 3.51 33958 Reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older 3.51 33959 Reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age 4.47 33962 Reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older 4.47 33963 Reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age 9.00 33964 Reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older 9.50 33965 Removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age 3.51 33966 Removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older 4.00 33969 Removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age 5.22 33984 Removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older 5.46 33985 Removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age 9.89 33986 Removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older 10.00 Initiation / Insertion Daily Management Reposition Removal Professional Coding

• Effective 10/1/2018
• ICD 10 Procedure Code 5A15223 deleted
• Three new codes are implemented; one for central access and two for

peripheral access

• Note: vascular access site does matter

Technical Coding Changes

ECMO – 5A15223 Deleted 09/30/2018 Central ECMO – 5A1522F Effective 10/1/2018 Peripheral VA-ECMO – 5A1522G Effective 10/1/2018 Peripheral VV-ECMO – 5A1522H Effective 10/1/2018

• ECMO will not automatically default to MS DRG 003
• Central ECMO still assigned to DRG 003
• Peripheral ECMO with fall under one of the following:
• DRG 215 - Peripheral ECMO with insertion of pVAD
• DRG 291 - Heart Failure & Shock with MCC or Peripheral ECMO
• DRG 296 - Cardiac Arrest, Unexplained with MCC or Peripheral ECMO
• DRG 207 - Respiratory System Diagnosis with Ventilator Support >96 hours or

Peripheral ECMO

• DRG 870 - Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours or

Peripheral ECMO

MS DRG Mapping Changes

• UKHC is still exploring impact on internal financials
• Below provided by LivaNova

Coding Changes Impact on Revenue

Peripheral VA ECMO (5A1522G)

DRG 291: Heart Failure & Shock with MCC or Peripheral ECMO ($7,492*) DRG 296: Cardiac Arrest, Unexplained with MCC or Peripheral ECMO ($8,551*) DRG 207: Respiratory System Diagnosis with Ventilator Support >96 hours or Peripheral ECMO ($31,165*) DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours or Peripheral ECMO ($35,057*)

Peripheral VV ECMO (5A1522H) Central ECMO DRG 003 ($101,892*) Peripheral VA ECMO + pVAD DRG 215 ($71,759*) Peripheral VV ECMO + pVAD DRG 215 ($71,759*)

• Program
• Capital Purchases
• Perfusion Equipment
• Purchase vs Lease
• Training
• Up front and ongoing
• Personnel
• Hospital and Professional
• UKHC currently has one FTE

solely dedicated to ECMO

• All others support various

functions

• Case Costs
• Capital Purchase
• Variable Supplies
• Will support departments be able

handle increased patient volume?

• Personnel
• Perfusionists vs ECMO Specialist

(RT / RN) Model

Program Costs versus Case Costs

• Identify Goals of the Program
• Right size the program
• Equipment and Staff to meet

Goals

• Buy vs Lease
• Perfusionists vs RT / RN Model
• Review Information
• Discharges
• Bi Monthly / Quarterly Program

Reviews

• Charge Capture
• Technical and Professional
• Daily Charges
• Order Set Reviews

Maximize Revenue – Minimize Costs

MOC II Activity

What should be included in the initial annual cost of an ECLS program?

• a. Capital supplies, disposable supplies, personnel and training, and

cost per case

• b. Capital supplies
• c. Hospital cost per case
• d. Staffing costs
• It is important to consider initial costs and annual costs for

maintaining an ECLS program. Estimating annual case volume can assist in predicting cost and potential reimbursement. All sources of cost must considered in order to make an accurate assessment of the program.

MOC II Activity

What types of CPT codes exist for ECLS cases?

• a. VV ECLS and VA ECLS
• b. Pediatric ECLS and adult ECLS
• c. Insertion, daily management, reposition, and removal for VV

ECLS and for VA ECLS in both adults and pediatrics

• d. Percutaneous and central ECLS

There are CPT codes for VA and VV ECLS in both pediatric and adult patients. Both VV and VA have insertion, daily management, resposition, and removal CPT codes. Within VA ECLS, there is also differing CPT codes for central versus percutaneous insertion.