physician-hospital economic alignment
DESCRIPTION
Physician-Hospital Economic Alignment. May 17, 2014. Becker’s Hospital Review Annual Meeting. Agenda : Three Components . Models and Strategy . Traditional Hospital-Physician Relationship. No relationship to quality, cost, or defined process. Independent Delivered Patient Care. - PowerPoint PPT PresentationTRANSCRIPT
PHYSICIAN-HOSPITAL ECONOMIC ALIGNMENT
Becker’s Hospital Review Annual Meeting
May 17, 2014
AGENDA: THREE COMPONENTS
• Goal is to Improve Quality, Process,
CostsHospital-Physician Alignment
• Opportunities for Care
Coordination, Waste
Reduction
Clinical Re-Design
• Documenting the Outcomes
of the RelationshipManage, Measure,
Compliance
2
3
MODELS AND STRATEGY
TRADITIONAL HOSPITAL-PHYSICIAN RELATIONSHIP
4
Physicianclinical
decisions
IndependentDelivered
Patient Care
HospitalPays for
Care
Independent decisions
No relationship to quality, cost,
or defined process
Inefficient & Uncoordinated Care
No concern for how
Products & Services are used
HOSPITAL-PHYSICIAN ECONOMIC RELATIONSHIP
5
Physicianclinical
decisions
Coordinated Patient
Care
HospitalPays for Better
Outcomes & Less
Utilization
Information Driven
Decisions
MD concerned about quality,
cost, utilization & process
6
MANY TYPES OF HOSPITAL-PHYSICIAN ALIGNMENT
• Bundled Payments
Risk Arrangements
• Gainsharing Type Models
Clinical & Cost Reduction
• Co-Mgt• Medical
Director
Clinical Improvement
7
NUMEROUS HOSPITAL-PHYSICIAN ECONOMIC MODELS
Co-Manageme
ntService Line
SpecificGeneral
Medicine, Cardiac, Ortho,
etc..
Pre-Set Payment Amount Divided
Evenly
Bundled Payments
CMS: Hospital Post Acute: Medical &
Surgical MSDRG. Gainsharing:
50% professional fees
Commercial efforts
Procedures & OB. Gainsharing
opportunities
OIG Approved Gainsharin
g14 approved OIG Cardiac, Ortho,
Spine & Anesthesia
Gainsharing:: 50% of identified
savings.
Three examples
THE OPPORTUNITY
Point A Point B
Process AnalysisReduce ComplicationsLearn costsManage with HospitalInvent New Processes
INFINITE WAYS TO DELIVER CARE TO SAME PATIENT TYPE RE-ENGINEER CARE
9
Average Suture Cost$622
10
Benchmark Average Cost $118
11
THE UNTAPPED POWER OF PHYSICIANS
10% Discount on Suture Cost/case: $622 Current annual suture
cost: $311,000Annual Savings:
$31,000
Obtaining Benchmark Level Utilization
Best in class Benchmark: $118
Annual Cost: $59,000Annual Savings:
$252,000
PRICE UTILIZATION
12
Appreciation to the staff of Chicago Health System, a part of Tenet Health
CLINICAL RE-DESIGN
13
HIGH COST/HIGH RISK PATIENTS
No single good predictive model
ACO: • HCC• Frequent ED• Frequent
admits• Doctor
referral
HMOI: Verisk model
Bundle: Care Team Connect
14
AMBULATORY
Identify gaps in
care
Get data into docs
hands
Help with process
of outreach
and coordinati
on
Help with office re-design
Diabetes, COPD/Asthm
a, CHF
Reduce ED visits
OBS vs. admits
STEPS FOR CHANGE BIGGEST BANG FOR THE BUCK
15
COMPLEX CASE MANAGEMENT
Identify high risk
Reach out to patient
with participation of PCP
Work with patient on coordination, self care
& investment
in their health
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
Complex Case Management Utilization by Program Duration
30 Day 60 Day 90 Day0
200400600800
10001200140016001800
020406080100120140160180
Admits per 1000Enrolled Members
Admits/1000Members
30 Day 60 Day 90 Day0
200
400
600
800
1000
1200
1400
020406080100120140160180
ER Visits per 1000Enrolled Members
Visits/1000Members
Visible trends in both charts, yet neither show statistical
significance
Sharp trends driven by a few high utilizers in a
relatively small pool of members
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17
Complex Case ManagementUtilization vs. Baseline
Pre-Enrolled Post-Enrolled Baseline0
500
1000
1500
2000
2500
Admits per 1000Dates of service from 10/12 to 9/13, with runout thru 11/13
Admits/1000
Enrolled Baseline0
200
400
600
800
1,000
1,200
0
500
1000
1500
2000
2500
ER Visits per 1000Enrolled vs Baseline
*> 6 months from start date
Visits/1000Members
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
Complex Case Management Total Medical Expense and Member Months
2012
01
2012
02
2012
03
2012
04
2012
05
2012
06
2012
07
2012
08
2012
09
2012
10
2012
11
2012
12
2013
01
2013
02
2013
03
2013
04
2013
05
2013
06
2013
07
2013
08
2013
09$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
0
50
100
150
200
250
Post-MbrMthsPre-MbrMthsPre-EnrolledPost EnrolledBaseline
July – September post significantly lower than pre
19
Hospital notification about ED and admissions for Bundles/ACO patients
Early assessment/enrollment into CCM
HOSPITAL
Hospitalist
LOS managemen
t
Care re-design for bundles
20
POST ACUTE STRATEGY
POST ACUTE PLATFORM ACROSS ALL STRATEGIES
ACOPatients
BPPatients
CCE
CHS
Others
• Service requirements• Metrics & Outcomes• PCP Connections• CHS Central Tracking
Financial Performance
Quality Metrics
Patient Experience
Growth
Preferred Provider Network
22
Used generally available quality criteria
Some additional work
Now push back on LOS for bundles
POST ACUTE PROVIDERS
History: Started with 140
SNF/rehab and 30 HH partners
Narrowed down to 5 HH and 30 SNF/Rehab
They all agreed to play nice in the sandbox
23
CRITERIA FOR POST ACUTE PROVIDERS
24/7 Geographic coverage EMR Visit frequency Employed RN Employed therapists JCO/CHAP certified
Medicare Medicaid Managed care Psych Wound Care
24
Monthly Jan Feb Mar Apr May Jun Jul Aug Sep
% of falls with injury
% pressure ulcers (facility acquired, non hospice)
% of UTI (facility acquired)
% residents receiving flu vaccine
% residents receiving pneumonia vaccine
% restraint use
% using in dwelling catheter (excluding present on admission for short term use)
% residents with significant weight loss
% residents receiving Hospice Services
% residents receiving Palliative Consultation Services
30 day readmission rate all causes
30 day readmission rate CHF, AMI, PN
MONTHLY SNF QUALITY REPORTING
25
MANAGE, MEASURE, COMPLIANCE
26
ELEMENTS OF SAFE HARBOR
Term of at least one year In writing by both parties Specify aggregate payment and set in advance Payment is reasonable and fair market value Compensation not related to volume or value of
business Exact services to be performed must be outlined Services are commercially reasonable
27
THE CHALLENGE IS EXECUTION
LEGAL
CONTRACTMGMT
DUTIESFAIR
MARKETVALUE
TERMS
28
TRACKING IS A MANUAL PROCESS
ROOM FORERROR
FRUSTRATING FORPHYSICIANS
COMPLIANCERISKS
EXPENSIVEMISTAKES
Paper process
29
DON’T BE THE NEXT HEADLINE
$12.5 M.
$39+ M.
$14.1 M.$9.3 M.
$85 M.
PEN
DIN
G
30
CONTRACT INTEGRITY AND PHYSICIAN ENGAGEMENT
Time Log Automation Financial Reporting
31
PHYSICIAN PAYMENTS – RISK CONTRACTS
Quality Measures Met?• Did physician reach the threshold for
payment, if yesCost Measures Met?• Did physician stay within cost expectation
for DRG
Physician Monthly Payment Made
32
ADJUDICATE AND ANALYZE
33
BEST PRACTICE
Payments to physicians should be made only with proper documentation
Check against agreement terms Invest in technology that prevents errors and
respects physician time Audit time log duties Adjudicate payments monthly and review all
agreements annually
34
CONTACT INFORMATION
Joane Goodroe, [email protected]
Gary Wainer, DO, [email protected]
Gail Peace, [email protected]