Bundled Payments Triangle Orthopaedics and BlueCross and Blue Shield of NC

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1 Bundled Payments Triangle Orthopaedics and BlueCross and Blue Shield of NC Elaine Daniels, Former Senior Strategic Network Consultant, BCBS North Carolina Chris Adkins, CAO, Triangle Orthopaedic Associates

2 Triangle Orthopaedic Associates, P.A. Large Multi-Specialty Group based in Raleigh/Durham, North Carolina 185 Providers including 65 Physicians 23 Locations 715 Employees 8 Orthopaedic Urgent Care Centers Ownership in a Specialty Hospital Ownership in an Ambulatory Surgical Center

3 BlueCross and Blue Shield of NC North Carolina s Largest Private Payor Serve over 3.9 million customers Employees over 4,800 North Carolinians PPO is predominate product 98% of MDs and 99% of hospitals are in network First payer live on bundled payment contracts in North Carolina

4 What is Bundling? Bundling (def) The act of binding things together.

5 What is Bundling? Bundling (Amish def) A onetime custom during courtship of unmarried couples occupying the same bed without undressing.

6 How Did We Come to the Table? 2011: Triangle Orthopaedics approached BCBS about a way to reduce costs and drive more patients to the practice 2011: BCBSNC provided a Prometheus/HCI3 report showing all patients with DRG 469 and : BCBSNC had already contracted with a small community hospital for a Retrospective Bundle (this laid some initial groundwork) 2011: TOA thoroughly dissected with Prometheus Report disputing some of the data

7 How Did We Come to the Table? 2012: Improper codes were found in the Prometheus data that led to a system upgrade 2012: TOA and BCBSNC began to discuss what is included and what is not included NC Dept of Insurance involved in final contract since TOA basically carried clinical risk in the contract December 1, 2012: A contract became effective after almost 2 years of negotiations

8 Bundle Contract: What s Included? Bundled Contract Details: -Prospective Payment Model CPT s: (TKA) (UNI Knee) (THA) NO Bilateral Procedures Comprehensive of Facility, Anesthesia, and all 90-day post-op care including DME and Physical Therapy, as well as complications as a result of the procedure

9 Bundle Contract: What did not work? Initially a 30-day pre-op period was included. Extremely difficult during reconciliation process Solution: Term is Date of Surgery to 90-days post-op Members that had secondary insurance or terminated coverage during the 90 day postop period Solution: Both of these scenarios are excluded Claims Processing: Initially very difficult for the payor to handle. Solution: TOA created a new NPI for Bundled Claims

10 Bundle Contract: What did not work? Member Benefits and Member Services Solution: Much education at BCBS with client services and at TOA with all employees Timely Reports Solution: Data from BCBS is and continues to be a delayed process. Need ease in reporting. BCBSNC purchased Aver Informatics to assist Downstream Compliance Solution: Constant oversight with Facility and Anesthesia providers filing claims accurately. Need a third party solution to assist AVER

11 Bundle Contract: What did not work? Deductible/Coinsurance/Copay Collection Solution: Much stricter collection of payment prior to surgery and explanation to patient of what is included in the bundled payment Quality Measures: When Payor Chooses Solution: TOA and BCBSNC worked together to achieve mutually agreeable quality measures PT Utilization Solution: TOA created a wellness program for Patients to transition to at no charge during the 90-day post-op period

12 Data Required TOA performed a thorough analysis of each physician along with their referral patterns and order sets to develop standards of care. BCBSNC provided aggregate costs from all sources by patient Cost and utilization data provided through Prometheus bundle algorithms

13 Engaging Physicians Let s face it most physicians do not handle change well TOA approached this as a way to keep the physicians income from decreasing through truly managing the care. Also, it was presented as a way to share in additional monies if the proper guidelines were followed The primary joint physicians were brought in during several meetings to mainly discuss standards of care and outliers were addressed by the group

14 Results So Far BCBS Commercial Bundle Approximately 550 patients (many are repeat patients) Nearly Zero Leakage Outcome/Quality 98% Patient Satisfaction Zero Re-admits/Zero SNF/HH Physical Therapy 6-12 weeks Savings BCBS/State Health Plan

15 What s Next? TOA and BCBSNC are looking to add additional Episodes of Care TOA and BCBSNC are working towards a payment model that truly promotes transparency to the patient where all costs are disclosed up front AVER will handle the reconciliation between TOA and BCBSNC. In addition, it will streamline claims processing, payments to downstream providers, and outcomes tracking

16 Other Bundles? Triangle Orthopaedics currently has the following bundled payment programs in place: CMS/Medicare BPCI Program Effective 1/1/2015 participating in DRG s 469, 470 and 483 OPTUM/United Healthcare Retrospective Bundle/Employer Directed with DRG s: 470, 460, 473, 520 CIGNA Episode of Care Gainsharing with no downside risk; DRG 470 Bridgehealth Retrospective Bundle/Employer Directed; Multiple DRG s

17 Chris Adkins, Chief Administrative Officer Currently at Triangle Orthopaedics since In Healthcare Management for over 20 years Graduated from Appalachian State University with a major in Healthcare Management

18 Elaine Daniels, Director Network Strategy Currently at Aver, Inc. Formerly Network Contract Management at BCBSNC for over 19 years Established the first prospective payment bundled contracts in North Carolina