The Business Case for Registered Dietitian Nutritionists in Value-based Health Care. Value. Compensation 3/3/2015

Transcription

1 The Business Case for Registered Dietitian Nutritionists in Value-based Health Care Meredith Alger, MS, RDN, LD South Carolina Academy of Nutrition and Dietetics March 4, 2015 Value How do you value yourself and your work? How do you determine your worth as a provider? How do you measure your contribution to your employer? To patients? Compensation How are you compensated? Compliance with guidelines Revenue/ profit contribution Front-end savings 1

2 Value proposition A promise of value to be delivered The primary reason a prospect should buy from you Explains how your product/ service Solves customers' problems Improves their situation (Why are you relevant?) Delivers specific benefits (how do you quantify your value) The RDN Value Proposition Do our stakeholders know why we are valuable? Providers Payers Patients Changing times New opportunities for RDNs Elevate the profession Expand and redefine scope of practice Align services with population health management needs Demonstrate value and worth through as critical members of integrated care team Capitalize on new payment models and reimbursement structures (P4P, bundled payments) Become leaders, pioneers and authors of the next chapter in U.S. Healthcare 2

3 Healthcare Delivery 1980s-2010s Prospective Payment System (DRGs) (1983) Medicare Hospital reimbursement Hoped for benefits were never realized- why? DRG Costs were not measured accurately created discrepancies between reimbursement levels and actual costs for certain services Fee-for-service, not global payment system no reason to improve efficiency or conserve resources DRGs were structured in a way that rewarded procedurebased medicine, surgery, interventions Effects of PPP (DRG) System Crowding into fields where DRG reimbursement higher (i.e. surgery, interventional, imaging, ortho) Less interest in lower reimbursed specialties (Peds, ER, PCP) Cross-subsidies Revenue v. Cost Centers Waste, overuse of resources Fee-for-service, Volume-based, supply-driven healthcare system In Brief PPP (DRG) systems est. in 1980s encouraged MDs to enter highly-reimbursed specialties (procedure-based, reactive medicine) Medicare/ Insurance does not reimburse well for consultation, counseling, preventive services (despite that these activities can add equal or greater value) 2 Rewards providers for seeing as many patients as possible (volume over value) Increased pressure with year-over-year decreases in Medicare/Medicaid/Insurance reimbursement rates This structure is perpetuating a low performing health care system where payment and performance incentives to keep people HEALTHY are misaligned with our current methods of practice! 3

4 Current State of Healthcare And it s really expensive! Treating patients with chronic diseases accounts for 75 percent of the nation's health care spending. New Strategy: Value-based Healthcare 4

5 Legacy System v. New System Definition of Healthcare Value Value = Outcomes + Quality Service Cost Achieving the best outcomes at the lowest cost Goal: improving value for patients If providers can show improvement in patient outcomes, they can sustain or grow market share even with constraints of new payment models New Strategy: The Value-based System 5

6 Organize around the customer and the need! Measuring Outcomes that Matter to Patients All five of us are very good at what we do, but we all do it differently. At least four of us must be doing it wrong. - Cardiac surgeon, Mayo Clinic Learning Improving performance Enabling value-based payment 2013 ICHOM. All rights reserved. When using this set of outcomes, or quoting therefrom, in any way, we solely require that you always make a reference to ICHOM as the source so that this organization can continue its work to define more standard outcome sets. What are the outcomes that matter to your patients? Not just compliance with your own protocols Functional health outcomes Quality of life Extent of physical activity Ability/ time to return to work Need for additional/ ongoing therapy or repeat intervention Risk of long-term complications 6

7 Measuring the Cost of Care Value = Health Outcomes Cost of delivering the outcomes Confusion about difference between costs and charges We don t know the true actual cost of delivering healthcare services Don t know how much time care processes take Existing hospital accounting systems are department-, not patient-based Cost Accounting Methods Ratio of costs-to-charges Top-down approach Department-based aggregated Designed for volume-based fee-for-service models Utilizes inaccurate and arbitrary cost allocations 6 Provides no incentive to reduce costs and improve processes to enhance outcomes Treatment Cost Multiply per min resource cost by activity time Determine the per minute cost of every resource that goes into taking care of a patient during a given care cycle Determine total amount of $ the organization has to make to remain viable Apply the ratio of treatment costs to charges Treatment Cost Time-Driven Activity- Based Costing Method Bottom-up approach Patient-based Designed to maximize value, deliver better patient health outcomes at lower cost Identifies actual cost of each resource used Supports ability to aggregate cost information across multiple organizations 6 MUSC TDABC Projects Built tailored Time-driven Activity-Based Cost estimation (TDABC) framework and applied to VIR and Pediatric Diabetes care cycles Currently expanding to complex/chronic disease care cycles in Diabetes, Orthopedics and Psychiatry Goal is to scale up and also partner with ICHOM to begin health outcomes measurement 7

8 Resource Legend 5 min $9 $5.01 $0.14 $28.58 $ min $13.96 $66.86 $13.68 $ min $5.01 $0.22 $9.77 $ min $4.89 $11.11 $15.64 $35.56 $ min $28.58 $0.22 $ $32.26 $30.09 $ min $3.91 $0.90 $4.89 $0.22 $1.86 $0.37 $45.11 $1.99 $30.08 $1.32 $ /3/2015 MUSC TDABC: VIR PILOT Ports ~ 10% all VIR procedures (representative of ~25% all VIR access procedures) Process mapped VIR port placement procedure care cycle in June-August 2014 Calculated capacity cost rates (cost per minute) for all resources (personnel, space & equipment, consumables, & indirects) in care cycle Built cost estimation tool to assign fully allocated costs to resources in process maps Designing and implementing value-based health care delivery models at MUSC MUSC TDABC: VIR PILOT Time Diven Activity Based Cost Map: VIR Port Placement (August 2014) Patient Registration P&R RN Start Prior to Day of Procedure 1. NPO Patient receives phone 2. Transportation call from P&R RN 3. Pre-Procedure Screening Form 4. Directions Day of Procedure Patient drives to appt. VIR Registration (5th Floor) Patient arrives to Patient sits in VIR Registration waiting room Prep and Recovery Patient arrives in Prep and Recovery P&R PCT Rad Tech Physician Procedure RN Consumables/ Supplies/ Equipment P&R RN reviews chart and calls patient Nurses station PCT stocks procedure room P&R RN stocks bay Procedure room 5 min 30 min 5 min Proc RN completes MD leads AM AM/PM Procedural Time-Out or Checklist Huddle Procedure room 5 min 5 min Patient Checked In Reception PCT escorts patient from Registration to P&R Hallw ay Proc RN completes Pre-procedure handoff report 4 min 30 min Indirect Costs Prep and Recovery Procedure Area Prep and Recovery MD consents Patient P&R Supplies Patient "READY" Patient is tabled in for procedure Procedure Begins Procedure Area Rad Tech 1. Discusses with MD whether special equip/supplies needed and stocks room 2. Sets up sterile back table and labels containers Procedure room Procedure RN confirms room ready and checklist done and transports patient Rad Tech and Procedure RN - 1. Patient on Table 2. Prep and Drape 3. Attached to monitors 4. Ask MD for Sedation Procedure room MD perfoms procedure Procedure RN assists as needed Rad Tech assists as needed Patient arrives in Procedure Ends Prep and Patient Discharged Recovery Procedure RN transports Patient back to P&R Post-procedure Checklist (Recovery) 5 min 45 min End Indirect Costs Procedure Supplies Procedure room Total Cost = $ RCC vs. TDABC Cost Comparison Cost $3, $3, $2, $2, $1, $1, $ $3, $1, The TDABC process calculated costs for VIR-PPP to be 49% of current applied organizational costs using the RCC accounting methodology. $0.00 RCC TDABC Method 8

9 Benefits of TDABC Denominator in Value Equation (Value= Outcomes/ Cost) Bundled payment contracts Implementation of TDABC models identifies internal division of single revenue payments Alternative compensation/reimbursement models for RDNs Population health management Chronic disease Directed patient care to centers of excellence Assure better patient care management through consistent standards of care Avoidance of adverse events from safety & quality breach Recap US Healthcare is expensive Most people don t currently receive care that is comprehensive and coordinated To address this: IHI has developed Triple Aim Affordable Care Act incents new value-based structure and payment models (ACOs, PCMHs, Bundles) What do these changes mean for RDNs? Multi-disciplinary teams will play a key role in meeting the challenge of caring for individuals in the next generation of healthcare -Joint Principles of the PCMH 9

10 RDNs Demonstrate Value Care coordination Patient-centered care Multi-disciplinary teaming Evidence-based care (MNT, patient self-management support, and care management services) PCMHs Quality Improvement Leadership Improvement in health outcomes for patients with a variety of medical conditions Population Health Management Public/population health models, upstream approaches to prevention and treatment of chronic disease Front-end Cost Savings What is Your new Value Proposition? "RDNs are uniquely experienced and positioned to be one of the critical professionals in our U.S. health care model, today and in the future " - Sonja L. Connor, President, Academy of Nutrition and Dietetics Call to Action How do we lead changes necessary to integrate the RDN into new models of care? Individual level Case-management Quality improvement (measure health outcomes) Empower current and future RDNs Profession level Define the value proposition that RDNs represent to patients across the continuum 7 Advance role of RDNs and position as integral part of PCMH and population health management models of care Advocacy Impact legislation at all levels that supports inclusion of and payment for RDN-provided services in new models of care 10

11 Value-based Healthcare Resources Harvard Business School Institute for Strategy and Competitiveness International Consortium for Health Outcomes Measurement (ICHOM) Institute for Healthcare Improvement (IHI) The Academy of Nutrition and Dietetics Patient-Centered Medical Home/ Accountable Care Organization Workgroup Emerging Health Care Delivery and Payment Models References 1. Porter ME. Redefining Health care: creating value-based competition on results. Boston, Mass.: Harvard Business School Press; Porter ME. A strategy for health care reform--toward a value-based system. The New England Journal of Medicine. Jul ;361(2): Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harvard Business Review. Sep 2011;89(9):46-52, 54, Porter ME. Why Health Care is Stuck- And How to Fix It. Harvard Business Review. Sep 2013; online content available at: 5. Kaplan RS, Witkowski ML, Hohman JA. Boston Children's Hospital: Measuring Patient Costs. Harvard Business Review. Case Report, Harvard Business School. 2012:28. References 6. Kaplan RS. Improving value with TDABC. Healthcare Financial Management: Journal of the Healthcare Financial Management Association. Jun 2014;68(6): Jortberg BT, Fleming MO. Registered dietitian nutritionists bring value to emerging health care delivery models. Journal of the Academy of Nutrition and Dietetics. Dec 2014;114(12): Emerging Health Care Delivery and Payment. Academy of Nutrition and Dietetics (2014). 11

12 Thank You Questions? Meredith Alger 12