fundamentals of bundles for joint replacement – creating the competitive edge
TRANSCRIPT
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Fundamentals of Bundles for Joint Replacement Creating the Competitive Edge
Maureen GearyProgram Manager
November 19, 2015
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• Opened in July, 2007 and has performed over 21,000 cases to date.
• CJRI is the most profitable service line at Saint Francis Hospital.
• Saint Francis Hospital has a consulting agreement with Connecticut Joint Replacement Surgeons to manage CJRI.
• Surgeons and Anesthesiologists are in private practice
Connecticut Joint Replacement Institute (CJRI)
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• The consulting agreement is a straight fee not a gain sharing model.
• Dedicated Space and Resources:
• 3 Floors
• 100 FTE (management, clinical, para professionals)
• Ancillary Services (Rehabilitation, Pharmacy, Housekeeping, Integrated Medicine)
Connecticut Joint Replacement Institute (CJRI)
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The Step Ahead Program was established in 2010.
Three Participants:
1. Saint Francis Hospital & Medical Center
2. Connecticut Joint Replacement Surgeons
3. Woodland Anesthesia Associates
Bundle Program
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Bundled Program Goals
Create a platform for care redesign to:
• Coordinate patient care
• Reduce variability
• Improve operational efficiencies
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What is a “Bundled Payment”
“Single package price for a comprehensive and specific set of healthcare services delivered to a patient by multiple providers over a defined period of time (Episode)”
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Essential Elements to Develop and Implement Your Bundle Program
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Build a Multi Dimensional Team
• Administration and Physician Leadership
• Multidisciplinary Team
Legal
Finance
Clinical
Revenue Cycle
Operations
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Define the Bundle
• Identify parties involved
• Define duties of each party
• Decide what is in/out
• Determine the timeframe
• Establish a warranty (if appropriate)
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Duties of Each Party: Hospital
Provide the necessary infrastructure including:
• Facilities/ staff • Support services• Finance/Operations
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Duties of Each Party: Surgeon
• Determine appropriateness for surgery
• Perform surgery
• Provide routine post-op in-patient care
• Adhere to guidelines and protocols
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Duties of Each Party: Anesthesia
• Review eligibility and risk stratification
• Provide anesthesia services
• Adhere to best practice and protocols
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Patient Criteria
• Patient under the age of 70 (non Medicare).
• Patients with either none or minimal systemic disease.
• 11 factors (BMI, major depression, chronic narcotic or alcohol dependency…)
• The criteria serves as guidelines and may be modified to the patient’s overall assessment.
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Determine Cost
• Hospital• Surgeon• Anesthesia • Re-admissions and Complications
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Define Quality Measures
• Re-admissions • Complications • HCAHPS scores• Length of Stay
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Engage your Physicians
Each Orthopedic Surgeon and Anesthesiologist that performs bundle payment surgery will participate in an in-service that outlines in detail their specific responsibilities, the protocols/best practices, and their own personal financial risks for non-compliance.
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Episode Starts
Episode Ends
Develop Care Maps
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1. Commercial Payers
2. Center for Medicare Services
3. Large Self-Funded Employers
4. Third Party Administrators
5. Large Primary Care Groups
6. Un-(or under) insured patients
Identify Potential Buyers
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• Bundle payment was an A + B + C model
• ½ of the patients were excluded from the bundle program due to anesthesia review
1st Commercial Contract
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Challenges
• Reverted to manual systems and rework.
• Required additional resources across the board.
• Lack of integrated systems to process claims and payments.
• Hospital assumes the financial losses related to co- pays and retro eligibilities.
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• Commercial payors are seeking to shift administrative tasks and risks to your bundle program while reducing overall payment.
• Promise steerage of patients to your organization.
Competing Priorities
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Refining your Program
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Physical Therapy Shift
• Patients admitted to the inpatient floor after 2 pm – only 20% ambulated.
• Develop a mobility technician program.
• Recalibrate certified nursing assistant and mobility tech role into one role
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Patient Ambulation - Mobility Program July – August
Post OpDay
Staff Type Ambulating the Patient Percentage Average Times Patient
Ambulated
0
Mobility Techs, Nursing Assistants and Registered Nurses 93%
2.1
Physical Therapy 7%
1Mobility Techs, Nursing Assistants and Registered Nurses 61%
4.6
Physical Therapy, Physical Therapy Assistant 39%
2Mobility Techs, Nursing Assistants and Registered Nurses 60%
4.2
Physical Therapy, Physical Therapy Assistant 40%
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Case Management
• Clinical oversight of patients should be only for those going to an extended care facility (less than 20% of patients)
• Shift work required to a highly skilled administrative assistant
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• Post acute spend was approximately $4,200
• Collaborating with post acute providers
Reference Based Model• Desired Outcomes
• Metrics and Measurement
Changing the Paradigm Post Acute Care
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Third Party Administrators New Book of Business
• Third party administrators are representing the employers
• Seeking regional centers of excellence
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Three Models
• Episode with the hospital stay
• Episode with readmissions
• Episode with post acute services
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Things to Consider
• Who is in control?
• New way of doing business (telemedicine)
• Assume readmissions for patients that are readmitted outside your network
• Assume costs for patients that don’t behave
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Evolution of Our Bundle Payment 2009 Formation of a multi-disciplinary team to explore
bundled payment programs
2010 Bundle Program was established
2012 Signed a bundled contract with Payor
2013 Partnership with Harvard Business School. Project lead with 30 organizations on Time Driven Activity Based Costing (TDABC).
2015 5 national contracts as regional center of excellence
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Creating a Competitive Edge
• Physician Leadership and Administration are essential
• Know your value
• Evolving and Refining your business model
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Questions
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Thank You
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Streamlining Orthopedic Episodes of Care
www.wellbe.me
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Seeking Speakers
OrthoServiceLine offers a $500 speaking honorarium for a 45-minute webinar and 15 minute Q&A from your desktop and phone.
We are currently seeking speakers for our 2016 webinar series.
Interested? Send an email to [email protected].
Also seeking speakers for our next LIVE MSK Leadership Summit – Tentatively March 30 in NYC!