A Guide for Bundled Payments This document reviews the considerations in establishing a bundled payment program for services provided to patients with dementia. In addressing dementia, there are two distinct services that neurologists offer, initial diagnosis and chronic disease management. It is suggested that two different bundles are appropriate. Given that there is little current precedence for bundled services for dementia, integrated services are also an option e.g. an initial diagnosis and management for the first year after presentation. Inherent in the consideration of any agreement for bundled payments is not only the included services but the excluded services. Dementia patients will suffer from other acute and chronic conditions. The agreement must carefully define what falls under the bundle and what does not. COMMON CONSIDERATIONS Cognitive impairment can take an enormous personal and financial toll that extends to family members. Skilled diagnosis and management is necessary while preserving dignity and respect. Compassionate and supportive care including support of caregivers including education and referral to community services is a critical component of treatment. Managing dementia represents a challenge for our fragmented health system. The vast majority of care for patients with dementia occurs at home and is provided by informal care providers such as family and friends. However, over time patients need increasing assistance that can only be provided through community services such as adult day care, respite care, and assisted living. Alternative payment models provide an opportunity to integrate services (even including emergency room and inpatient services); improving care and communication; and avoiding duplication, inappropriate, or unnecessary care. Ongoing and initial management requires addressing safety concerns and behavioral dysfunction and support of the caregiver, avoiding caregiver burnout, and assessing the adequacy of the home environment to meet the patient s needs. Coordinated team management can meet the dual goals of improved quality (the quality of care as well as the quality of life for the patient and caregivers) and reduction in costs. Topics addressed will include treatment goals, clinical course, prognosis, diagnostic confidence, risk mitigation, warm handoffs to ensure connection to needed community resources, planning long-term care options, and social and behavioral techniques to manage foreseeable disease complications that may occur unpredictably. Risks include financial mismanagement, physical debility and falls, lack of advanced financial planning and arrangements for medical decision-making, social isolation, living arrangements and support that are inadequate to accommodate the patient s needs, inadequate diet, safety concerns such as becoming lost and safety issues revolving around dangerous operation of appliances, firearms in the home, and driving. Opportunities for cost savings in dementia include 1) building confidence among patients, their family members, and other health providers to avoid redundant testing, multiple consultations, and second opinions, 2) providing sufficient patient and family education and support to avoid unnecessary crises in care resulting in emergency visits and hospitalizations, 3) care planning to improve adherence to management plans of co-morbid medical problems, 4) advanced planning for palliative care to avoid futile interventions, 5) delaying the need for placement in long term care facilities and 6) avoiding futile care. Finally, when appropriate using non-physician specialists such as social workers, to increase team efficiency and cost-effectiveness. QUALITY METRICS Validated quality metrics are limited for dementia. Quality metrics so far focus on process, for example those developed by the American Academy of Neurology Dementia Measures Workgroup. Widely employed quality of life metrics for patients and care partners are not yet available and represent a research opportunity in the care of dementing diseases. Some work has been done on caregiver-reported outcomes as components of research studies. Individual programs could build on the surveys employed in these studies. However, common measures across programs may permit better comparison and set optimal management. Outcomes metrics for both the diagnostic bundle and chronic management are needed. Below are the metrics recently developed by the AAN Dementia Measures Work Group (note these measures will be updated in 2015). Dementia Episodes of Code 1
Only if the client can provide PDF file, I can make the image sharper TRAINING The care of dementia patients is provided by multiple physician specialties and by many other health care providers. The leader of the team has traditionally been a physician with expertise in dementia diagnosis and management. Decisions as to the appropriate evaluation of patients, the use of diagnostic tests and establishing treatment plans require the experience of an expert provider. Techniques to support the patient and care giver all require the knowledge and experience of providers with expertise in the management of dementia and are often provided by a team of health care providers including advanced practice nurses and social workers. Typically, the team caring for this population includes non-physicians and requires considerable coordination of care. Training for the entire team in the medical and psychosocial aspects of dementia including drug treatment and contraindicated medications, typical and atypical disease presentations, common complications of specific dementing diseases, options for assistance in care, techniques to improve quality of life, how to achieve caregiver mastery, and manage behavior in the home is critical. ADMINISTRATION AND INFRASTRUCTURE Inherent in a bundled payment for dementia is the preemptive ability to identify the pre-contract cost of care and the opportunities for savings and improved care. Further, systems must capture both the metrics and cost data in a timely fashion. A great deal of planning needs to go into the development of the monitoring system. The capture must be easy, intuitive, and yet comprehensive enough to be meaningful, all of which represents a considerable challenge. A dedicated coordinator that covers all phases is a critical component. It is recognized that transitions in care are difficult. Staff should be educated and tasked with the transitions from the acute hospital to rehabilitation and from rehabilitation to home care. Dementia Episodes of Code 2
Finally, there is need for a monitoring committee or single individual that has both the responsibility and authority to manage and monitor the project. Yet many of the services extend well beyond the scope of the usual in office management. Experience as well as the recent Medicare Payment Advisory Commission (MedPAC) report emphasize that the greatest opportunities to lower cost and improve outcomes are in the post-discharge/follow-up phase. Oversight must extend unequivocally to this phase. EPISODE 1. INITIAL COGNITIVE EVALUATION AND DIAGNOSIS Determining the cause of dementia requires a comprehensive assessment and the judgment of a skilled physician to select and interpret the significance of appropriate diagnostic investigations. Confirming the presence of dementia and identifying its cause is essential to appropriate management. Otherwise care can be inconsistent. Prognosis, management, as well as patient and family education and counseling, are dependent on the underlying disorder. Population: Patients presenting with cognitive disorders are highly diverse. Bundled payments are meaningful only when a reasonably coherent population can be defined. Thus, the population must be clearly defined including inclusion and exclusion criteria. That population can include individuals without a deficit, subtle but progressive disorders such as leukodystrophy, or even a rapidly progressive dementia. For the purposes of a bundled care contract, it might be appropriate, though not necessary, to exclude certain patient populations. Age: Consider excluding young onset dementia with a cut off of age less than 60. Presentations in this age group often are atypical, requiring more extensive testing or may represent those who have only changes of normal aging. Pace of disease: Rapidly evolving dementia is uncommon, but requires a different evaluation and potentially could be excluded from bundled dementia services. Duration of disease: If the intent of the program for the patient population included in the bundled payment contract is to focus on dementias of the elderly, patients entered into the bundle should have evidence of a progressive cognitive disorder for at least six months. Initial diagnostic evaluation: The bundle is intended to include the comprehensive diagnostic evaluation to determine the cause of dementia and to rule out reversible causes, including diagnostic testing; and a management plan that includes drug and non-drug treatment recommendations, patient and family education and support including access to respite care, coaching to promote caregiver self-management, planning for future care, and follow up visits sufficient to evaluate response to treatment. Duration: The duration of time included in the bundle usually should be one year, sufficient to achieve these goals of establishing a diagnosis and initiating management,. The duration is by necessity arbitrary but must be reasonable for the contract with the payers. Clinical Services: Clinical services fall into four categories: Diagnostic: These include a comprehensive history, neurological and mental status examination, including involvement of a knowledgeable informant who also can serve as a care partner to assist in keeping appointments and help effect the care plan. Testing usually includes a standard battery of blood tests, neuroimaging, and neuropsychological testing. Ancillary testing such as CSF or PET imaging may be necessary on occasion. A challenge for the determination of the bundle is to estimate the frequency that ancillary testing will be required Risk assessment and remediation Education and care planning: Counseling and support should exist hand in hand with the diagnostic evaluation Care coordination: Coordination of care with other health providers and identifying responsible care partners are critical to the effectiveness of dementia care and to achieve cost savings. Consequently, care coordination is critical and should be specifically recognized and included in the bundled services. EPISODE 2. CHRONIC MANAGEMENT OF DEMENTIA A wide spectrum of physicians and other health care services care for these patients. While the dementia expert may have a limited role in providing direct care, that expert should be the clinical leader of the team. The understanding of dementia syndromes and the management of these patients are rapidly becoming more complex, requiring expert oversight. Not all patients who receive a diagnostic assessment are appropriately included in the chronic management bundle. For example, patients with reversible or static dementia, or mild cognitive impairment, require fewer resources for management. Opportunities to monitor or improve the quality of care delivered or to reduce short-term costs through improved management are limited in this population. Population: Patients with a disease causing a chronic progressive cognitive disorder. This presumes that a diagnostic evaluation has been completed so the cause is Dementia Episodes of Code 3
known, a management plan is in place, and education and planning have been completed. Potential inclusions: Potentially individuals with a static dementing disease or developmental disorder could be included given the similarities of the services, but it would be expected that changes in management would be less frequently needed. Geography: Depending on the included services, such as home visits, the population may be restricted by geography based on the availability of services. Potential exclusions: The population will include patients with various causes and severity, requiring different services and different intensity of services. As noted above, specific narrowing of the patient population leading to a reasonable coherent population may be appropriate. For example, institutionalized patients may be excluded from the bundled contract. On the other hand, it is recognized that there will be substantial variation in the population included in the arrangement, not only based on the severity of the dementia but also based on the underlying cause of the dementia syndrome. Duration: The duration of the bundle is arbitrary. A year is a reasonable consideration. Clinical services: Most of the services for chronic management do not require a physician and are covered under common considerations. Physicians would be responsible for assessing unexpected changes in the patient s condition, periodic review of medication management, and periodically reevaluating the adequacy and effectiveness of the management plan, with specific common issues being management of depression, evaluations to determine the causes of delirium, and assessment of capacity for decision-making as it evolves over time. Establishing coordinated protocols including referral to home care services, respite care, and community agencies such as the local Alzheimer s Association would be part of start-up costs. EPISODES GROUPERS There are few neurology-focused episode groupers available. To design an episode of care from scratch using a data derived model could be quite expensive. Payers would need denominator specifics (detailed ICD-9-CM and ICD-10-CM codes), CPT codes, and any applicable pharmaceutical and device specifications. Here is a list of ICD-9-CM diagnosis codes that could be used to define a dementia episode of care. Here is a list of ICD-10-CM diagnosis codes that could be used to define a dementia episode of care. ICD-10 Diagnosis Code A52.17 General paresis F01.50 Vascular dementia without behavioral F01.51 Vascular dementia with behavioral F01.51 Vascular dementia with behavioral F01.51 Vascular dementia with behavioral F02.80 Dementia in other diseases classified elsewhere, without behavioral F02.81 Dementia in other diseases classified elsewhere, with behavioral F03.91 Unspecified dementia with behavioral F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition G30.9 Alzheimer s disease, unspecified G31.01 Pick s disease G31.09 Other frontotemporal dementia G31.83 Dementia with Lewy bodies Dementia Episodes of Code 4
SOURCES: Emanuel E.J. and Steinmetz A. Will physician lead on controlling health care costs? JAMA. 2013; 4: 374-375. Available at: http://jama.jamanetwork.com/article.aspx?articleid=1719718 Medicare Payment Advisory Commission. 2013. Report to the Congress: Medicare and the Health Care Delivery System. Washington, DC: MedPAC 2014 Alzheimer s Disease Facts and Figures. Alzheimer s Disease Association. 2013. Duru OK, Ettner SL, Vassar SD, et al. Cost Evaluation of a Coordinated Care Management Intervention for Dementia. Am. J. Man. Care. 2009;15:521-534. Callahan CM, Arling G, Tu W, et al. Transitionf in Care for Older Adults with and without Dementia. J. AM. Geriatr. Soc 2012;60:813-820. Vickery BV, Mittman BS, Connor KI, et al. The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care. Ann. Intern. Med. 2006;145:713-726. Doody RS, Stevens JC, Beck C, et al. Practice parameter: Management of dementia (an evidence-based review). Neurology 2001;56:1154 1166. Odenheimer G, Borson S, Sanders AE, et al. Quality improvement in neurology: Dementia management quality measures. Neurology 2013;81;1545-1549 Published online before print September 25, 2013. Dementia Performance Measurement Set. American Academy of Neurology, American Geriatrics Society, American Medical Directors Association, American Psychiatric, Association. Physician Consortium for Performance Improvement (PCPI) approved October 2011. Available at: https://www.aan.com/uploadedfiles/website_library_ Assets/Documents/3.Practice_Management/2.Quality_Improvement/1. Quality_Measures/1.All_Measures/dementia.pdf Logsdon RG, Gibbons LE, McCurry SM, Teri L (1999). Quality of life in Alzheimer s disease: Patient and caregiver reports. Journal of Mental Health & Aging, Volume 5, Number 1, pages 21-32. Logsdon RG, Gibbons LE, McCurry SM, Teri L (2002). Assessing quality of life in older adults with cognitive impairment. Psychosomatic Medicine, 64, 510-519. Dementia Episodes of Code 5