IHI Expedition Expedition: Preparing Care Teams for Bundled Payments - - PDF document

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IHI Expedition

Expedition: Preparing Care Teams for Bundled Payments Session 6: Case Study - CMS Bundled Payments for Care Improvement Experience June 2, 2015

Begins at 1:00 PM

Evan Benjamin, MD, FACP Stephanie Calcasola, MSN, RN-BC Jan Mayforth, CPA Douglas Salvador, MD, MPH Molly Bogan, MA

Today’s Host

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Akiera Gilbert

Project Office Assistant Institute for Healthcare Improvement

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Expedition Director

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Molly Bogan, MA

Director Institute for Healthcare Improvement

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Expedition Objectives

At the end of this Expedition, participants will be able to: Describe the benefit of transitioning to a value-based purchasing model Understand and apply activity-based cost accounting methodology to at least

• ne care process

Demonstrate examples of how to engage stakeholders in building a bundle Describe how to customize care team redesign to deliver optimum care under value-based purchasing

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Today’s Agenda

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• Introductions
• Session 5 Action Period Assignment Debrief
• Case Study: CMS Bundled Payments for Care

Improvement Experience

• Action Period Assignment
• Closing

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Expedition Sessions

Session 1: Volume to Value; Describe the benefit of transitioning Value- Based Purchasing Lead Faculty: Lucy Savitz & Trisha Frick Session 2: Getting Started with Building a Care Bundle Lead Faculty: Trisha Frick & Nick Bassett Session 3: Collecting Data Using Activity-based Costing Lead Faculty: Nick Bassett & Lucy Savitz Session 4: Engaging Stakeholders in Bundle Design Lead Faculty: Trisha Frick & Nick Bassett Session 5: Care Team Redesign Lead Faculty: Trisha Frick & Nick Bassett Session 6: Case Study: CMS Bundled Payments for Care Improvement Experience Lead Faculty: Stephanie Calcasola, Evan Benjamin, Jan Mayfort and Doug Salvador

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Action Period Assignment Debrief

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• Build an outline for designing optimum care team end-to-end based
• n data collected in sessions 1, 2, 3 & 4.

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Faculty

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Evan Benjamin, MD, FACP Senior Vice President/Chief Quality Officer for Baystate Health Springfield, MA Stephanie Calcasola, MSN, RN-BC Director of Quality and Medical Management Baystate Medical Center Springfield, MA Doug Salvador, MD, MPH, Vice President of Medical Affairs Baystate Medical Center Springfield, MA Jan Mayforth, CPA Director, Clinical Financial Planning and Decision Support Baystate Health Springfield, MA

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Baystate Medical Center’s Experience with Bundled Payments

Institute of Healthcare Improvement June 2nd 2015

Evan Benjamin, MD, FACP Stephanie Calcasola, MSN, RN-BC Jan Mayforth, CPA Douglas Salvador, MD, MPH

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Award Recognitions

2013

Why Do Bundle Payments?

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What is a Bundle

• An integrated model to deliver to patients, families,

referring physicians and payers substantially improved quality and value for a defined set of health care services by:

• Redesign of complex systems to embed evidence based best

practices reliably;

• everyday patient flow => better outcomes cheaper
• Activating patients and families to be engaged in the care

processes;

• Aligning the interests of the patient, provider, payor and

purchaser.

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8 Steps to A Bundle

1. Convene the right team 2. Define the episode 3. Develop measures 4. Develop model of care 5. Price the bundle 6. Develop cost reduction opportunities 7. Plan the gain-sharing 8. Develop a continuous process improvement plan

BMC Baseline Bundled Care Target Post Implementation % Patients readmitted 30 days 0.5 % Patients discharged to home 68.8 80 88 % Patients with any hospital acquired complication (UTI, HAPU, DVT, Post-

• p sepsis, complication of anesthesia,

SSI) SCIP Measures (% ACS – all or none) 97.5% 98.5 100 Bundled Cost $24,600 $22,900 Patient Experience HCAHPS* “Overall Rating” 6.78 >8 8.62 Mortality

Early Work: 2010 Bundle Commercial Pilot Total Hip

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Current Bundle Initiatives

Center for Medicaid & Medicare Innovation (CMMI) Total Joint

• Total Hip & Knee Replacement ( DRGs 469, 470)
• CABG (DRGs 231-236)
• Colorectal – Active July 2015 (DRGs 329, 330 & 331)
• Oncology Care Model –LOI submitted; June 19th

application is due Commercial Health New England

• Obstetrics (Planning Phase)
• Total Joint (Contract finalization)

Building the Improvement Infrastructure

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Developing Model of Care: Total Hip Care Model Measure Description Data Source Time Period Comparison Standard NQF Discharge Anti- Lipid Treatment Society of Thoracic Surgeons (STS) Current available quarter STS Mean NQF CABG 30-day readmission Premier QA CMMI Claims All patients isolated CABG National Mean SCIP Antibiotic Timing Premier QMR Index surgical episode CMS Benchmarks Post –Acute Provider # of patients discharged to Pref Providers Chart Abstraction Index discharge Internal

Quality Metrics (Sample)

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Reducing Variation in Care

Post-Acute Opportunity DRG 470 -Major Total Joint w/o MCC

Time Frame Total Volume ALOS # Cases SNF* (%) National Benchmark Well Managed Benchmark

7/09- 6/10 447 3.4 300 (67.1) 47.9% 37.5% 7/10- 6/11 448 3.5 325 (68) 47.9% 37.5% 7/11- 6/12 228 3.4 228 (68) 47.9% 37.5% *Does not include LTC and Acute Rehab

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Post-Acute Model Redesign Post-Acute Work Summary

• BH Strategic Post-Acute Care Committee
• Post-Acute Preferred Partnerships
• Bundle Navigator Role
• Post-Acute Care Oversight Work Group
• Transitions in Care/Cross Continuum

Collaboration/Readmission Prevention

Goals of Strategic Partnerships

BH Strategic Post-Acute Care Committee

• Creating the overarching strategy for Post-acute

care (PAC) for the BH hospitals

• Providing a single point of decision making around

PAC relationships

• Assuring that the strategy is consistent with other

BH approaches to PAC

• Creating a Preferred Provider Partnership Network

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Post-Acute Preferred Partnerships Quality and Operational Performance

Collaborative Partner Facility Profiles

• Facility demographics
• Quality performance (star rating, readmissions, falls, etc.)
• Provider model
• Services (dietitian, rehab, 24/7 access)
• Citizenship
• Patient satisfaction
• Staffing
• Professional Development (certification)
• Environment aesthetics

Bundle Navigator Role

• Provide oversight of care coordination and quality monitoring

working in partnership with case management, post-acute partnerships.

• Work to develop and ensure streamlined operations, patient

satisfaction and care navigation in the episodes of care bundle model.

• Knowledge around national best practice standards,

transitions of care, regulatory rules and requirements for post-acute care; skilled in improvement methods and project management; proficient in data management (excel, access, database mining)

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Post-Acute Oversight Team

• Established relationships with key leaders in post-

acute facilities

• Leadership and clinical compliment stakeholders
• Monthly meetings
• Education and sharing around bundle, care design,

improvement opportunities

• Care pathway redesign
• Quality outcome and expectations (structure,

process and outcome deliverables)

• Bundle performance

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Transitions in Care

• Risk screening on index admission
• Targeted intervention for high risk patients
• Standardized education tools
• Medication reconciliation
• Follow up phone calls
• Appointments made before discharge
• Active cross continuum teams
• Automated readmission notification EMR
• PAC Performance Improvement Teams
• Savings from 2 sources
• Over entire bundle episode – savings would accrue 100% to

insurer without gainsharing arrangement

• Based on reducing cost through better management of in-

hospital services billed outside the DRG (MD consultations), reduced readmissions and reduction in post-acute services (both % of patient receiving service and cost of services received)

• Costs incurred while patient is in hospital – savings would accrue

to hospital without a gainsharing arrangement

• Use benchmarking to identify areas of opportunity
• Premier Bundled Payment Collaborative provided benchmarks
• n readmissions and post-acute services
• Premier Quality Advisor – DRG LOS and Cost benchmarks
• Internal data from decision support system – comparisons

between providers and service item level detail comparisons.

Determine Opportunities for Cost Savings

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Internal Cost Savings

TOTAL JOINT CMMI BUNDLE

Cases Variable Cost per Case Cases Variable Cost per Case CY14 v. FY13 ANESTHESIA 570 $90 546 $91 $1 BLOOD PRODUCTS 267 $161 92 $60 ($101) CARDIOLOGY 9 $3 4 $0 ($2) DIAGNOSTICS 570 $277 546 $200 ($77) EMERGENCY DEPARTMENT 22 $12 26 $16 $5 NURSING 570 $2,050 546 $2,098 $49 OUTPATIENT 9 $1 7 $1 $0 PHARMACY 570 $280 546 $327 $47 STATISTICAL CODES 570 $1 546 $0 ($1) SUPPLY 570 $6,270 546 $6,251 ($20) SURGERY 570 $2,383 546 $2,514 $130 TREATMENT 570 $608 546 $584 ($24) TOTALS 570 $12,136 546 $12,143 $7 CY14 FY13

CABG CMMI BUNDLE

Cases Variable Cost per Case Cases Variable Cost per Case CY14 v. FY13 ANESTHESIA 114 $51 138 $47 ($4) BLOOD PRODUCTS 98 $1,154 75 $413 ($741) CARDIOLOGY 116 $938 142 $453 ($485) DIAGNOSTICS 117 $1,654 142 $1,338 ($316) EMERGENCY DEPARTMENT 37 $101 28 $68 ($33) NURSING 117 $10,455 142 $9,738 ($717) OUTPATIENT 8 $6 12 $8 $2 PHARMACY 117 $1,113 142 $1,238 $126 STATISTICAL CODES 117 $19 142 $23 $4 SUPPLY 117 $3,450 142 $3,311 ($139) SURGERY 117 $4,759 142 $5,364 $605 TREATMENT 117 $873 142 $824 ($49) TOTALS 117 $24,572 142 $22,825 ($1,747)

• 7.11%

CY14 FY13

Blood Product and Diagnostic testing savings offset by increases in : Nursing – LOS decline offset by cost per day, Surgery – flat minutes offset by increase in cost per OR minute Significant cost savings in blood products, cardiac cath lab, and Nursing (1.9 day LOS reduction)

• ffset by increase in OR

reduction in minutes per case

• ffset by increase in cost per

minute)

Key Factors Driving Savings

Total Joint Replacement

• Reduction in discharge to SNF (66% vs. 61%)
• Lower LOS in SNFs from work with Preferred Providers
• Use of Preferred Providers – 77% of patients
• Decrease in ALOS at preferred providers (14.5 vs. 8.5)
• Lower discharges from SNF to Home w/o VNA
• Lower LOS in Acute Rehab Facilities (16 vs. 11 )
• DRG 469 – more patients paid under transfer rule – low

LOS then discharged to post acute

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• Must have waiver from CMMI/CMS
• Must include quality measures at MD level – no gainsharing if

quality targets not met, considered at individual provider level

• Minimum number of cases – don’t want to reward non-

participating MDs

• Net Payment Reconciliation Amounts (NPRA) from CMS
• Amount saved in excess of the 2% discount
• Next 2% kept by Awardee hospital to recoup amount withheld by CMS
• Savings in excess of 2% contributed to gainsharing pool
• Internal Cost Savings – Hospital cost savings identified using

internal cost accounting system.

• Commercial bundle shared all savings with MDs

Lessons Learned Around Gain Sharing Total Joint Performance

CMMI Total Joint Replacement Bundle CY 2014

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CABG Performance

• Executive Leadership Support
• Tightly aligned physician partners critical at the outset
• Start engaging teams early!
• Gain sharing discussions take time
• Care model determines practice. Cost reduction

follows.

• Post-Acute Partnerships Collaboration
• Improvement and Accountability Infrastructure
• Data analytics are integral to measurement, improvement,

celebrations and opportunities We must be able to measure comprehensive value of all care in an episode

Michael E. Porter, PhD, N Engl J Med December 2010

Summary

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Questions/Discussion

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Raise your hand Use the chat

Action Period Assignment

Take the learning from today’s case study and test the design from Session 5’s action period with focus group from your care team Complete end of program survey – link will be emailed Look for the final resources list and summary slides to be shared on the listserv

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Expedition Communications

• All sessions are recorded
• Materials are sent one day in advance
• Listserv address for session communications:

bundledpaymentexp@ls.ihi.org

• To add colleagues, email us at info@ihi.org

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Thank You!

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Director: Molly Bogan mbogan@ihi.org Akiera Gilbert agilbert@ihi.org

Please let us know if you have any questions or feedback following today’s Expedition webinar.