BUNDLE PAYMENT CARE INITIATIVE: Improved Care with Less Expense Joseph L. Verzal, MPAS, PA-C DISCLOSURES

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1 BUNDLE PAYMENT CARE INITIATIVE: Improved Care with Less Expense Joseph L. Verzal, MPAS, PA-C DISCLOSURES I have no financial disclosures pertinent to this presentation. 1

2 GOALS Define the Bundle Payment Care Initiative (BPCI). Understand how to make it successful. Show you how we have had to evolve to provide better care for less cost. Is it a good model, and is it sustainable? SINGH JA, YU S. ARTHRITIS RHEUMATOL. 2017: 69 (SUPPL 10) 2

3 BUNDLE PAYMENT DEFINITION An agreement between Medicare (CMS) and Hospital/Surgeon groups, to provide quality care for less cost, while incentivizing those hospitals and surgeons for their efforts. The Care Episode for the patient will be designated as the 2 days before surgery and the 90 days after. Any costs incurred during this time frame will come from the bundle payment, target price CMS is offering. This is based on regional cost analysis and traditional payments for previous episodes billed. EXAMPLE #1 CMS Target Price = $23K Patient costs over the 92 days = $21K (Home after 2-3 days in Hospital and no issues the 90 days after discharge) $23K - $21K = $2,000 Gain share for the Hospital and Surgeon 3

of $42K Negative result = - $21,000 10 healthy patients to

4 EXAMPLE #2 CMS target price $23K Out of the hospital for $21K Swing $1,500/day for 14 days = $21K Total Cost of $42K Negative result = - $21, healthy patients to offset and recover that $21,000! ITS NOT ALL CHERRIES AND ROSES! 4

5 HERE S THE KICKER! If the spend during the 90 days is below the medicare target price, then the hospital will receive a positive Net Payment Reconciliation Amount to distribute as gain share. If the spend exceeds the medicare target price in the 90 day period, then the hospital will have to write medicare a check for those costs that exceed the target price. All done in the Reconciliation period. WHAT BUNDLE PROGRAMS ARE NOT We do not cut corners We do not skimp on care We do not force people to go home We do not tell people they cannot go to a swing bed or nursing home 5

6 WHAT A BUNDLE PROGRAM IS Started to encourage collaboration among providers, hospitals and payers It prepares and optimizes patients for best outcomes It educates patients for their best result after a Total Joint Replacement It allows patients to have a direct role in their care Encourages best outcomes because it is based on Best-Practices data The intent is, Better Healthcare at a Lower Cost Encourages all to work together, for a better outcome HOW DO YOU GET IT DONE? 6

7 ORGANIZATION 1 - Physician Developed Program with Physician Leadership 2 - Anesthesiology 3 - Physical Therapy Speed Recovery Short acting blocks to ensure rapid mobilization Initiate Physical Therapy on the day of Surgery IT ALL STARTS AT THE BEGINNING! It MUST start at the Surgeon s office! What the Surgeon says is Gospel! Locked in memory from the start! What the Primary Care Provider says is Gospel as well! However, patients have different perspectives on life and how medical processes have been, and should be done. They also read the internet and talk with their friends and buddies at the coffee shop! Disclosure statement given to patients, informing them of our participation 7

A familiar voice, a familiar face, a trustworthy person for patients to rely on.

8 NURSE NAVIGATOR CARE COORDINATOR REAL SUCCESS STARTS HERE! Nurse Navigator is there for the patient and their family. A relationship is started and established from the beginning. A familiar voice, a familiar face, a trustworthy person for patients to rely on. Present in the pre-operative phase with education, through the hospital stay, and follows them after discharge. The TRUE CONNECTION between the patient and the clinical/hospital team via , standard mail, and phone calls. In place to avoid Hospital Readmissions and ER Visits to reduce costs. 8

9 CHI GOOD SAMARITAN JOINT REPLACEMENT CLUB Pre-operative class to educate and prepare patients for the hospital visit. Joint Replacement Club team An entire Hospital floor, (3North) and care providers specifically trained to care for the total joint patient. Team Members 1 Physician Assistant, 1 Nurse Navigator, 2 Physical Therapists, 1-2 Care Managers, and The Best Orthopedic Nurses on 3 North to care for you! Total Joint Replacement Class starting at 2:30pm Tuesday, and then 10:30am and 2:30pm, Wednesday through Friday Pain management by direct communication among team members. PRE-OP CLASS Describe the Surgery (Total Hip, Total Knee, Total Ankle) Discuss the Hospital Stay (Admissions, Pre-op, Surgery, Recovery, Orthopedic Floor) Discuss Expectations (You can do this!, Coach or Care Partner ) Give Tips and Hints for an Optimal Outcome (OT/PT recommendations and practice) Emphasize going Home (Eat better, Sleep better, Move better) 9

HOW DO I PREPARE FOR A TOTAL JOINT SURGERY? Think of your surgery as an athletic event. Preparation and Strengthening! Typically 1-2 days in the hospital, after your surgical day.

10 HOW DO I PREPARE FOR A TOTAL JOINT SURGERY? Think of your surgery as an athletic event. Preparation and Strengthening! Typically 1-2 days in the hospital, after your surgical day. You Tube Video Just Google. Joint Replacement Club Exercises Strengthen the Quadriceps and Hip Abductor muscle groups Ahead of time, determine who will be your Care Partner or Coach at home, once dismissed from the Hospital. PAIN CONTROL The Bell Curve (Medicine is Personality management) Previous or Current Narcotic use! UGH!!! (The Real Challenge!) 10

11 PAIN CONTROL EXPECTATIONS 0-10 scale with facial expressions 0 = You are asleep 4 = No worse than what you are currently experiencing Goal : Maintain a 4/10 or less 5-8 IVP medicine to get back on track > 8 we need to do something different HOME SOONER AND SAFER! Adductor Canal Blocks for Total Knees Intra-articular injections during the Total Knee Procedures Aspirin for DVT prophylaxis vs other anticoagulants which cause more bleeding and more swelling in the recovery phase. Extra-medullary guides for cutting the Distal Femur = less bleeding Strong in-house PT/OT programs to teach patients Post-operative exercises the first week, which focus on strength, instead of ROM! Incentive spirometry, hourly and daily, until follow up, to decrease readmissions for atelectasis or pneumonia. 11

WHAT DO YOU MEAN I HAVE TO PLAN FOR THIS ELECTIVE

We ve had to change the mindset of the patient from the

INSURANCE DOESN T SYMPATHIZE WITH PATIENT S SOCIAL

I already set up my swing bed with my doctor at home.

12 WHAT DO YOU MEAN I HAVE TO PLAN FOR THIS ELECTIVE PROCEDURE? We ve had to change the mindset of the patient from the start! INSURANCE DOESN T SYMPATHIZE WITH PATIENT S SOCIAL CONCERNS! I already set up my swing bed with my doctor at home. My spouse is in the nursing home that I want to go to for my recovery. My ride to take me home doesn t come through town until Thursday. My wife doesn t like to drive in this weather. But X, Y, Z is what I did last time. 12

13 GOOD SAMARITAN DATA Length of stay Readmissions 30 day 2.97% 0.97% Discharge SNF 17% 5% Discharge - Swing Bed 9% 3% HCAHPS Overall Rating 76.8% 80.7% KEYS TO SUCCESS IN A BUNDLE PROGRAM Busy and Successful Surgeon, with great outcomes! Nurse Navigator! Larger Hospital with Anesthesia and Surgical teams on board with the same game plan in mind! Physical Therapy / Occupational Therapy for safe return / transition home! Great Communication among team members for the same goal! 13

14 IS IT GOOD AND SUSTAINABLE? It is the start of a good model for health care savings. It has taught US, to work together. Adjustments need to be considered for higher risk individuals with more co-morbidities. WE NEED YOUR HELP! We appreciate the support and understanding of the Family practice and Internal Medicine offices to support our goal to return people home. Obviously what Primary providers preach is Gospel as well. At some point patients start believing or buying into what we tell them vs. what they read on the internet or heard at the coffee shop. We continue to support and reinforce the surgeon s initial statement of returning home throughout the entire process: Before, during, and after the hospital stay. Optimize the patient before surgery 14

15 AS OF JANUARY 1 ST 2018 Medicare has placed Total Knee Replacements on the Outpatient Surgical list. This action created confusion, anxiety, as well as unexpected consequences. Hospitals and Providers interpreted this change many different ways. Each had their own perspective, as a Hospital, Surgeon, or Payer. Nationwide Confusion!!!! Concern for unsafe conditions for patients. (Froimson M.D., AAHKS Position Statement, February 21, 2018) Just because you change an admission status, it doesn t mean you change Grandma! --- Joe Verzal PA-C HOW TO PREPARE YOUR H&P #1 - Describe Co-morbidities as being Optimized State, The patient is maximized for risk reduction, instead of The patient is cleared for surgery. In other words, The patient is at their most stable place for Surgery or Cardiac Risk Stratified vs Cleared for Surgery. 15

16 HOW TO PREPARE THE H&P #2 Describe the management linked to the Diagnosis: Example: DM Type I, Patient will require IV Insulin and it may be unknown the amount of Oral intake needed in the first hours. Example: COPD, OSA, Chronic Narcotic Use, Patient will require CO2 monitoring because of retention in these conditions and may require the more than 2 midnight stay. OTHER EXAMPLES Example: Pain Control, The patient had a specific block for pain after a total knee. I anticipate the block wearing off and the patient may require IVP rescue medicine. Adequate pain control has not been established at this time. Example: Obesity or Morbid Obesity, The patient is obese and I anticipate a delayed return to normal ambulatory status. This may require greater than two midnight stay, to achieve return to normal ambulatory status. 16

17 QUESTIONS? 17

Euclid Hospital CMS BPCI Episode

Euclid Hospital CMS BPCI Episode Two Paradigms in Health Care Reform Managing population 1 health, 2 PCMH Managing episodes of care, Bundled payments Health Status Baseline Episode Total Spend: Commercial