Getting Started with Bundled Payment for Orthopedics

Transcription

1 Getting Started with Bundled Payment for Orthopedics 1 GABRIELLE WHITE, RN. CASC EXECUTIVE DIRECTOR AMBULATORY SERVICES & NETWORK DEVELOPMENT HOAG ORTHOPEDIC INSTITUTE CONTINUUM CARE ADVISORS [email protected]

2 Background 2 Hoag Orthopedic Institute [HOI] orthopedichospital.com / hoioutcomes.com Orthopedic Surgery Center of Orange County [OSC] OSCOC.com First global in 2008/09 - OSC Global TPA OSC Global cash -OSC Bundled pilot HOI Commercial bundle HOI > 250 global and bundled episodes

3 Our objectives 3 Create change in payment model Improve care Align providers Provide value Volume Demonstrate success

4 Definition 4 A bundled payment is an all inclusive price that covers the cost of facility and professional services related to a specific procedure over a specified period of time that may or may not include a warranty

5 Facility $ Warranty Professional 5

6 Bundled example 6 Total knee arthroplasty DRG 470 CPT ICD Episode admission > 90 days Includes all care related to index procedure Excludes SNF, Home Health, care and procedures not related to index procedure, bilateral procedures Admission > discharge > post op care up to 90 days

7 Global example 7 Total knee arthoplasty DRG 470 CPT ICD Episode admission > discharge Includes all care related to index procedure during hospital stay Excludes care following discharge and procedures not related to index procedure, bilateral procedures Admission > discharge

8 team monitor episode Claims bundle Manage risk payers Outcomes 8

9 Team 9 Team selection Clinical Roles Administration Support services Communication Meetings Reporting

10 Team 10 Hospital/facility Coordinator / project lead connect the dots Physicians surgeon anesthesia Internist Nursing Administration Contracting Revenue cycle Benefits Registration

11 Team 11 Professional Coordinator liason with hospital MD office lead Anesthesia Internist Other Revenue cycle contracting benefits patient coordinator

12 Team 12 Patient Communicate what why how when Educate

13 Episode 13 Procedure Predictable High volume Known cost Known outcomes Included Excluded Time line Warranty

14 Manage risk 14 Patient selection Safe surgery Health status BMI <38 ASA 1-2, 1-3 Medical history

15 Manage risk 15 Providers Volume Quality Outcomes Cost

16 Warranty 16 Length Inclusions Exclusions Manage risk Provider data Self insured Re insurance Manage timeline

17 Outcomes 17 Quality benchmarks Volume ALOS SSI DVT/PE rate Re admission Claims

18 Manage cost 18 Reduce waste Do what is necessary/best practice Consider outcomes & risks Know cost data per provider Standardize Work with vendors Share savings

19 Payers 19 Commercial Employers Private pay

20 Payers 20 What do they want? Payer roadblocks Payer concerns How will they benefit?

21 Hospital Surgeon Anesthesia Other professional 21

22 MD Payer Hospital 22

23 Claims 23 Align all providers Pricing Data Who will manage claims? Who will manage payments? Process Contract between providers Risk pool?

24 Claims 24 Pre procedure Post procedure/episode One claim / multiple providers One check / multiple providers Coordination Payer concerns

25 Communication 25 facility surgeon Other professional providers Bundled alert!

26 Communication 26 Patients Providers Episode start > end Outliers

27 Care redesign 27 Align providers Claims management Share risk Standardize care Navigators Pre admission screening Infection prevention Transfusion rates Vendors

28 Provider contracting 28 Facility Surgeon Surgeon assistant Anesthesiologist Other Hospitalist Radiologist Pathologist Cardiologist

29 Benefits 29 Improve quality and outcomes Reduce cost of care Change from FFS Payers/employers want Solutions & change Price predictability Reduced costs Risk sharing Alignment Share in savings & success

30 Early Road blocks 30 Communication Payers Providers Knowing costs Knowing data/outcomes Process change Risk sharing Price setting Claims management Warranty Risks

31 Monitoring success 31 Monthly reports Revenue cycle Performance improvement Peer review

32 True & trusted leaders Payers Procedure Length of episode Warranty Inclusion exclusion Providers involved Data Rates Claims management Outcomes Getting started 32

33 Getting started 33 Cash global Commercial global or bundled arrangement Employer global or bundled arrangement Consider a pilot Start small

34 In a nutshell Align providers Build the team Select high volume, predicable procedures Patient selection criteria Define the episode of care start to finish, what it includes Determine the bundle price, what it includes and excludes Provider selection criteria Define quality metrics to be met and monitored Determine who will manage claims and payments Identify interested payers Educate Monitor the program Communication Keep it simple

35 - 35 THANK YOU!