Anticoagulation Anticoagulation ManagementManagementPaul Liss MD MS CPEPaul Liss MD MS CPEChief Medical OfficerChief Medical Officer

Marshfield ClinicMarshfield Clinic

Goals of the CMS ProjectGoals of the CMS Project

Encourage coordination of Part A and Part Encourage coordination of Part A and Part B ServicesB Services

Promote efficiency by investment in Promote efficiency by investment in administrative structures and care administrative structures and care processesprocesses

Reward physicians for improving outcomes Reward physicians for improving outcomes and reducing costsand reducing costs

Performance on both Performance on both process and outcome process and outcome

quality indicators, together quality indicators, together with cost savings, will be with cost savings, will be used in the calculation of used in the calculation of performance bonusesperformance bonuses..

Marshfield Clinic Marshfield Clinic –– Strategic Strategic DirectionDirection

Improve consistency of care and reduce Improve consistency of care and reduce costs for chronic disease conditions.costs for chronic disease conditions.

Use EBM care processes consistent with Use EBM care processes consistent with the IOM 6 aims (safe, timely, effective, the IOM 6 aims (safe, timely, effective, efficient, equitable, patient centered).efficient, equitable, patient centered).

Statement of the Current SituationStatement of the Current Situation

Substantial variation in management of Substantial variation in management of anticoagulation services exists.anticoagulation services exists.

These pts can have a complex array of These pts can have a complex array of medical issues (medical issues (AtrialAtrial Fibrillation, CHF, Fibrillation, CHF, ValvularValvular Heart Disease, etc)Heart Disease, etc)

Staff EducationStaff Education

6 to 8 week education program.6 to 8 week education program. Testing for initial competence, ongoing Testing for initial competence, ongoing

feedback and education.feedback and education. 6 week on6 week on--line certification course through line certification course through

Southern Indiana University.Southern Indiana University.

Anticoagulation Care Management Anticoagulation Care Management Program.Program.

–– Rigorous staff knowledge requirements and Rigorous staff knowledge requirements and trainingtraining

–– Medical Director oversightMedical Director oversight–– Quality Management Quality Management –– formal monitoring of formal monitoring of

metrics and outcomes.metrics and outcomes.

Pilot Program ResultsPilot Program Results

408 Cardiology pts(223 controls)408 Cardiology pts(223 controls) More consistent testingMore consistent testing More often within therapeutic rangeMore often within therapeutic range Less hemorrhagic complicationsLess hemorrhagic complications Significant decrease in all cause Significant decrease in all cause

hospitalizationshospitalizations

Anticoagulation: Anticoagulation: An Example of Better, Less An Example of Better, Less Expensive Care Made CostExpensive Care Made Cost--Prohibitive by Current Prohibitive by Current

Reimbursement PolicyReimbursement Policy

Major Adverse Events

Annual Incidence of All-Cause

Hospitalizations

% Time INR Values are within

Therapeutic Range

National 15%

Clinic Control Group

6.7% 0.70 60.4%

ACS Group 2.98% 0.41 73.7%

OutcomesOutcomes

All cause hospitalizations All cause hospitalizations –– ACS Managed = 0.41ACS Managed = 0.41–– Clinic Managed (NOT in ACS) = 0.70Clinic Managed (NOT in ACS) = 0.70

Study Study –– 4/99 4/99 –– 7/20017/2001

Patient satisfaction scores > 85% Patient satisfaction scores > 85% excellent rating.excellent rating.

High physician satisfaction for care of their High physician satisfaction for care of their enrolled patients.enrolled patients.

Enrollments Enrollments –– Current and futureCurrent and future

4, 143 patients currently enrolled in 4, 143 patients currently enrolled in standardized program.standardized program.

3,792 additional patients available for 3,792 additional patients available for enrollment.enrollment.

Additional Lessons learnedAdditional Lessons learned

Patients on anticoagulation are complex Patients on anticoagulation are complex management problems, especially with co management problems, especially with co morbid disease states (oncology).morbid disease states (oncology).

Maintaining expertise requires:Maintaining expertise requires:–– Regular dosing with 250 patients/dosing poolRegular dosing with 250 patients/dosing pool–– Minimum 3 RNMinimum 3 RN’’s for appropriate staffings for appropriate staffing

RNRN’’s in system can not add ACS role to current s in system can not add ACS role to current responsibilities responsibilities –– 3 centers failed.3 centers failed.

Productivity ExpectationsProductivity Expectations

Literature standard Literature standard –– 225 patients/RN FTE225 patients/RN FTE PAH productivity is > 250 patients/RN FTEPAH productivity is > 250 patients/RN FTE Productivity of RNProductivity of RN’’s monitored regularlys monitored regularly

–– Performance improvement plans used if Performance improvement plans used if necessary to meet goals of outcomes and necessary to meet goals of outcomes and productivity.productivity.

Financial Impact Financial Impact --11

Exhibit 1: Average Cost per Hospital StaySource: American Hospital DirectoryData on File as of Calendar Year Ended 12/31/2004

St. Joseph's (Mfld)

Aspirus (Wausau)

Howard Young

(Woodruff)Sacred Heart (Eau Claire)

Luther Midelfort (Eau

Claire)Riverview

(Wis Rapids) Average

Average Charges per Inpatient Stay $19,975 $16,583 $13,259 $15,562 $16,777 $10,914 $15,512Average Charge for Cardiology (medical) Stay $9,975 $10,849 $9,649 $11,256 $11,508 $9,481 $10,453

AUsed lower of two averages

Financial Impact Financial Impact -- 22Exhibit 2: Estimated Cost of ACS NurseCosts Based on Dept 717 Care Management, as of June 2005Prepared August 3, 2005

Current Model - Care Management NurseDirect Salary 53,181$ Direct Benefits 16,595$

Subtotal Salary and Benefits 69,776$ Support Staff (25% of NC Costs) 17,414$ Supplies & Computer (per NC FTE) 1,585$ Grand Total Cost of Care Nurse 88,775$

Built Up Cost - Care Management NurseDirect Salary 53,181$ Direct Benefits 16,595

Subtotal Salary and Benefits 69,776$ *Health Unit Coord (1 HSC : 5 NC) 6,959$ *Assistant Mgr (1 Asst : 10 NC) 7,751

Subtotal Care Support Staff 14,711$ Supplies & Computer (per NC FTE) 1,585 Grand Total Cost of Care Nurse 86,072$ *Staffing ratios updated 8/24/05, per M. Follen

Cost of Nurse Clinician includes the support staff necessary to handle call volume and

BUsed lower of two calculations

Financial Impact Financial Impact --33

Insu

rance

Hos

pitaliz

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Unique P

atien

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Hos

pitaliz

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Rat

es

Hos

pitaliz

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Unique P

atien

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Hos

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Rat

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Per P

atien

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Tot

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Total

Unique P

atien

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for C

arrie

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Patients in ACS Unmanaged PatientsSHP Advocare 331 268 1.24 476 317 1.50 0.27 84.48 657FHC 135 109 1.24 144 83 1.73 0.50 41.20 214SHP Group 70 65 1.08 159 109 1.46 0.38 41.62 185SHP MC Employees 51 41 1.24 95 68 1.40 0.15 10.41 114SHP Medicare 7 6 1.17 21 21 1.00 (0.17) (3.50) 29Blue Cross 364 321 1.13 930 671 1.39 0.25 169.12 1124WPS 81 66 1.23 204 153 1.33 0.11 16.23 243WEA 73 60 1.22 138 91 1.52 0.30 27.28 178Total 1112 936 1.19 2167 1513 1.43 0.24 386.84 2,744

[a]

[a] Difference between Total Unique Patient Count and the sum of patients in the ACS and unmanaged patients are those patients being managed within provider practices or one of the satellite programs.

Financial Impact Financial Impact --44

Cost-Benefit Analysis of ACS Management, by CarrierSummary SheetFor the 12 Months Ended 6/30/2005

Insu

rance

Car

rier

Unm

anag

ed M

ember

Populat

ion

Tot

al AC M

ember

s (Uniq

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Patien

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Avo

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per

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er Y

ear

Avo

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ss C

ost o

f

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Nurs

e FTE R

equire

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(225

Pat

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per N

urse)

Cos

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urse M

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Nurs

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(225

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urse)

Cos

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Unmanaged Members Total AC MembersSHP Advocare 317 657 0.27 $883,083 1.41 $121,266 2.92 $251,331FHC 83 214 0.50 $430,683 0.37 $31,751 0.95 $81,864SHP Group 109 185 0.38 $435,006 0.48 $41,697 0.82 $70,771SHP MC Employees 68 114 0.15 $108,864 0.30 $26,013 0.51 $43,610SHP Medicare 21 29 (0.17) ($36,586) 0.09 $8,033 0.13 $11,094Blue Cross 671 1124 0.25 $1,767,762 2.98 $256,687 5.00 $429,979WPS 153 243 0.11 $169,624 0.68 $58,529 1.08 $92,958WEA 91 178 0.30 $285,193 0.40 $34,811 0.79 $68,093

Total 1513 2744 4,043,629$ 6.72 $578,788 12.20 $1,049,699

Cost per Hospitalization (Exhibit 1) $10,453 Cost per Nurse (Exhibit 2) $86,072

* Financials not reflective of risk management savings.

CMS PGP Demo ImpactCMS PGP Demo Impact

5,537 patients on warfarin, 3,211 are 5,537 patients on warfarin, 3,211 are potential CMS eligible.potential CMS eligible.

Projected savings to CMS $5,205,651.Projected savings to CMS $5,205,651. Approximately 2,075 of the 3,211 Approximately 2,075 of the 3,211

potential CMS eligible patients are in the potential CMS eligible patients are in the ACS management program.ACS management program.

Staff resource requiredStaff resource required

RN FTE needed to manage 3,792 patients RN FTE needed to manage 3,792 patients in system in system –– @ 250 patients/FTE = 15.2@ 250 patients/FTE = 15.2–– @ 300 patients/FTE = 12.7@ 300 patients/FTE = 12.7

Health Service Coordinator FTEHealth Service Coordinator FTE–– 1 HSC/800 patients = 4.7 coordinators1 HSC/800 patients = 4.7 coordinators

Goal is to have system in place in next 6 Goal is to have system in place in next 6 months.months.

Actions RequiredActions Required

–– Centralize ACS by region, improving efficiency Centralize ACS by region, improving efficiency & reducing duplication of processes/costs.& reducing duplication of processes/costs.

–– ACS care management standardization to ACS care management standardization to quality.quality.

–– Approve RN resources for ACS programs by Approve RN resources for ACS programs by region.region.

Anticoagulation: Anticoagulation: An Example of Better, Less An Example of Better, Less Expensive Care Made CostExpensive Care Made Cost--Prohibitive by Current Reimbursement Prohibitive by Current Reimbursement

PolicyPolicy

5,000 patients/year on warfarin5,000 patients/year on warfarin

Medicare Savings: $11.67 millionMedicare Savings: $11.67 million

Patient Savings: $2.5 million Patient Savings: $2.5 million

Marshfield Clinic Costs: Marshfield Clinic Costs: (~$1.4 million)(~$1.4 million)

Reimbursement: Reimbursement: $0.00$0.00–– Dr. Hillman Dr. Hillman –– Testimony to CongressTestimony to Congress

Other IssuesOther Issues

Out of State LicensingOut of State Licensing EMR needsEMR needs Extension to other diseases states Extension to other diseases states

(e.g. CHF requires 1 RN/150 pts)(e.g. CHF requires 1 RN/150 pts)