ACHP Affordability Discussion Specific Cost Savings Strategies

Transcription

1 ACHP Affordability Discussion Specific Cost Savings Strategies December 17, 2014

2 ACHP News and Upcoming Events Recent Affordability Profiles: Asthma Home Visiting and Case Management program (UCare) Behavioral Health Case Management (CDPHP) Low-Risk Chest Pain Protocol (HealthPartners) Reduced Blood Utilization (Select Health) Heart Failure Clinic (Security Health Plan) Care Partners for Frail Elders (Independent Health) Use of Clinical Pharmacists (GHC- SCW) Shared Decision-Making (Group Health) Improved PAC and SNF Performance (Geisinger Health Plan) 2

3 Specific Cost Savings Strategies Payment Reform Models: Stephen Perkins, M.D., Vice President, Medical Affairs UPMC Health Plan Improved Clinical Efficiency: Gretchen Leiterman, Vice President, Operations and Hospital Specialty Services, HealthPartners William Nelson, M.D., Ph.D., Department Head, HealthPartners Cardiology and Medical Director, Regions Hospital Heart Center 3

4 Value Based Payment Initiatives Knee and Hip Replacement Bundled Payment Model ACHP Webinar 12/17/2014

5 Bundled Payments Episode Consist of many moving parts Payment negotiation, allocation, billing, claims adjudication, reconciliation Trigger Rules Standard Care Pathway Inclusions/Exclusions Duration PCP Orthopod Imaging - MRI Cardiologist Pre-op Lab PCP Cardiologist Take-home Supplies Orthopod Pharmacy PT Orthopod PCP Pharmacy PT Orthopod Pharmacy Cardiologist PCP Pharmacy Facility Facility Episode Of Care 1 month Pre-op Surgery Date Readmission /Reoperation 1 month Post-Op 3 month Post-Op Diagnostic Triggering Event Follow-up Care 5

6 Alternative Payment Methodologies Objective - Incentivize physicians to deliver quality care across the entire episode of care in a cost-efficient manner Four examples of potential payment models: 1. Shared Savings (Retrospective Reconciliation) 2. Retrospective Bundled Payment 3. Prospective Bundled Payment 4. Global Capitation All payment methodologies are subject to quality and clinical pathwayadherence standards in order to receive any incentive payments Considerations when determining the appropriate payment model Definition of continuum of care / pathway Participation / buy-in from providers Quality benchmarks / standards Utilization benchmarks / standards 6

7 Hip and Knees Shared Savings Initiative: Program Overview Program Objective: Incentivize physicians to increase quality of care by: 1. Adhering to an evidence-based pathway, and 2. Choosing the most cost effective implantable devices and supplies Program Criteria: Pilot period effective from July 2013 to July 2014 UPMC Health Plan is the patient s primary insurer Patient is a Commercial Fully Insured/ASO or Medicare member Patient is receiving a total hip/knee replacement (MS DRG 469 & 470) Acuity Level 1 and 2 only as determined by APR DRG Patient is discharged to home 7

8 Quality Criteria Professional & Ancillary Services Operating Room Supply Costs Physician CLAIMS Savings Physician COST Savings Professional & Ancillary Services Savings shared between Health Plan and physician Based on evidence-based clinical pathway Includes 30 days pre and 90 days post-surgery All costs of episode of care, except DRG Bundled Payments only apply to elective procedures acuities 1&2 Quality Threshold (80 points) Physician Shared Savings Payment Operating Room Supply Costs Savings reduce Health Plan payment to hospital Savings shared between hospital and physician Based on best practice 8

9 Hip and Knees Shared Savings Initiative: Physician Scorecard Quality (7/1/ /31/2013) Total Surgeries By Physician: 3 Hips and Knees Shared Savings Initiative Physician Scorecard - Quality SAMPLE Period: 7/1/ /31/2013 Quality of Life (SF12) 9 Measure Adherence to Pathway: Order Sets Blood Utilization Surgical Site Infections 90-Day Readmission* Pulmonary Embolism Patient Satisfaction Functional Assessment (Physical Therapy evaluation) Eligible Surgeries Eligible Surgeries Surveys Returned Pre-Surgical 3 2 Post-Surgical 3 0 Pre-Surgical 3 3 Post-Surgical 3 2 The quality scores must be at or above 80/100 by year end reconciliation in order for physicians to be eligible to receive savings. Score Goal (Threshold) Maximum Potential Points Meets Goals? 100.0% > 60.0% 25 Yes 0.0% < 10.0% 5 Yes 0.0% < 1.0% 10 Yes 0.0% < 1.0% 10 Incomplete 0.0% = 0.% 5 Yes 100.0% >= 75% 10 Incomplete N/A, no post-surgical follow-up Patients do not show overall improvement 5 Pt Improvement Any Improvement Incomplete Incomplete

10 Hips and Knees Shared Savings Initiative: Key Metrics Surgeries Hip Replacements Commercial Medicare Surgeries Hip Replacements Commercial Medicare Pre-Surgical Testing Lab CBC with Platelets PT-INR BMP UA and C&S MRSA Culture All Other Total Avg. # of Tests Avg. $ per Case Selected Key impactable areas Avg. # of Tests Avg. $ per Case Inpatient Stay Specialty Consults PCP Consult Pain Service Cardiology Initial Follow Up Initial Follow Up Initial Follow Up Total Avg. # of Consults Avg. $ per Case Avg. # of Consults Avg. $ per Case Radiology Hip Unilateral 1 View Hip Unilateral Complete Minimum 2 Views Hips Bilateral 2 Views Anteropost Pelvis Chest, 2 Views, Frontal & Lateral Post-Surgical Rehab* Physical Therapy Home Health (Nurse) Home PT Avg. # of Visits Avg. $ per Case Selected Key impactable areas Avg. # of Visits Avg. $ per Case EKG All Other Total Outpatient PT Total 10

11 Target OR Supplies, Pharmacy, and Blood Cost Labs PA s Radiology Nursing Staff OR and Equipment Usage Anesthesia Recovery OR Costs OR Supplies* Room and Board Pharmacy Blood Products Physical Therapy OR cost distributions provided for example/reference purposes only Hips Target Costs: Implant Blade Catheter Drain Dressing Pharmacy Blood Knees Target Costs: Implant Additional Implant Components Blade Catheter Cement Pharmacy Blood *OR Supply costs are based on FY2012 supply items charged to patients. They do not include low-cost items such as sutures, drapes, gloves and reusable instruments. They also do not include any supplies used but not documented in Surginet.

12 Claims Cost per Episode and OR Supply Costs Maximum 75 th Percentile Average Median 25 th Percentile Minimum 12

13 Hip and Knee Shared Savings Pilot Update 13

14 UPMC Value Based Payment Timeline Hip/Knee Shared Savings Time Frame July 2013 July 2014 July 2014 July 2015 Model Retrospective Reconciliation of Claims Acuities 1 and 2 only Hip/Knee & Low Risk Delivery Prospective Bundled Payments Time Frame July 2015 July 2016 Model Single bundled payment for entire continuum of care July 2013 January 2015 July 2015 Spine Shared Savings Time Frame January Model Retrospective Reconciliation of Claims Separate bundles for lumbar and cervical fusion 1. Further implementation of AVER Bundled Payment Software 2. Contracting with external providers 3. Other potential bundles 1. COPD 2. Hysterectomy 3. CHF 4. CAD 5. AMI 14

15 Questions? Stephen Perkins MD Tom Aubel Vice President, Medical Affairs Director of Medical Payment Strategy & Policy 15

16 Presenters have nothing to disclose ACHP AFFORDABILITY WEBINAR LOW RISK CARDIAC PROTOCOLS: REDUCING COST & IMPROVING CARE December 17, 2014 Gretchen Leiterman Vice President, Operations & Hospital Specialty Services William Nelson, MD, PhD Department Head HealthPartners CV Service Line Medical Director, Regions Hospital Heart Center

17 Affordability Profile: Improving low risk cardiac care Organizational Overview Triple Aim Results Low Risk Chest Pain Protocol Next Steps Low Risk Congestive Heart Failure Protocol Low Risk Atrial Fibrillation Protocol

18 HealthPartners Not-for-profit, consumer-governed Integrated care and financing system A team of 21,000 people Health plan 1.4 million health and dental members in Minnesota and surrounding states Medical Clinics 1 million patients 1,700 physicians Park Nicollet Health Services HealthPartners Medical Group Stillwater Medical Group 55 medical and surgical specialties 45 primary care clinics Multi-payer Dental Clinics 60 dentists, 21 locations Seven hospitals Regions: 454-bed level 1 trauma and tertiary center Methodist: 426-bed acute care hospital, featuring the Jane Brattain Breast Center Lakeview: 97-bed acute care hospital, national leader in orthopedic care Hudson: 25-bed critical access hospital, award-winning healing arts program Westfields: 25-bed critical access hospital, regional cancer care location St. Francis: 86-bed community hospital (partial owner) Amery: 25-bed critical access hospital, joining HealthPartners January 1, 2014

19 Regions Hospital & HealthPartners Collaborating to improve quality, experience & cost Joint Commission One of the top performing hospitals in the nation for heart attack, heart failure, pneumonia and surgical care First hospital in Minnesota to be named a Certified Comprehensive Stroke Center Distinguished Hospital for Clinical Excellence Among HealthGrades top 5 percent of hospitals in the nation for high-quality outcomes Among America s 100 Best Hospitals for pulmonary care, stroke care and critical care Minnesota Hospital Association Safe from Falls, Safe Skin, Safe Site, Safe Count, Safe Account Recognized by MHA and the March of Dimes for reducing early elective deliveries Recipient of 2013 Good Catch Award for patient safety Critical Care In 2013, the American Association of Critical- Care Nurses (ACCN) honored Regions SICU with its Beacon Award for Excellence Regions inpatient heart and vascular unit received the same award in 2010 and 2012 Top Hospital Leapfrog Top Hospital, the most competitive hospital quality award in the country. Only urban hospital in Minnesota to earn this recognition Awarded Grade A in The Leapfrog Group Hospital Safety Score. Environmental excellence Received award from Practice Greenhealth for achieving benchmarks in energy conservation, mercury reduction pollution prevention and recycling Community benefit 2013 Anti-Stigma Award from Minnesota National Alliance on Mental Illness Recognized as a Leader in LGBT Healthcare Equality by the Human Rights Campaign Electronic Medical Records Named Most Wired by Hospital and Health Networks magazine four years in a row

20 Results: Leapfrog Group - Quality and Resource Use Regions Hospital

21 Results: HealthPartners Heart Attack (AMI) Regions Hospital 100% 95% 90% 85% 80% Core Measure Outcomes 94% Patient Satisfaction 0.84 Total Cost of Care 81% % 96% AMI Core Measure Bundle Includes* Aspirin at Arrival and Discharge ACE1 or ARB for LVSD Smoking Cessation Counseling DECREASE Total Cost Index (compared to statewide average). Less than 1 is better than network average INCREASE percentage of patients who Would Recommend Regions Hospital

22 Low Risk Chest Pain

23 Low Risk Chest Pain Protocol - Background Implemented in September 2011 Collaboration between Cardiology, Emergency Medicine and Hospital Medicine Aim: Standardize care for Low Risk Chest Pain patients to improve the patient experience, ensure safety (using evidence to guide treatment), and reduce costs to the system Three years of consistent performance and positive outcomes

24 Innovation: HealthPartners Low Risk Chest Pain Program Regions Hospital Typical US Patient Experience: ER evaluation hospital observation admit 1-2 day stay (often includes noninvasive imaging) home HealthPartners Low Risk Chest Pain Protocol: Rapid ER evaluation TIMI Risk score 0,1 Negative troponin at 0 and 6 hours Low risk group (most) home stress test next day (echo/nuclear, 7d/wk) $2600 savings per patient

25 Chest Pain - Volume Trend ( ) Regions Hospital Growth 2,000 1,800 1,600 1,599 1,582 1,616 1,400 1,200 1,068 1,236 1,308 1, , , YTD Annualized Inpatient Observation LRCP

26 Percent of Cases Performed Outpatient , Medicare 36% 27% 21% 16% Length of Stay for Common CV Cases Condition/ Procedure 1-Day LOS 1 or 2-Day LOS AMI 17% 34% Chest Pain 40% 67% Arrhythmia 2 25% 49% Carotid Stent 61% 75% CEA 3 56% 74% Heart Failure 9% 27% PCI ICD Implant Hypertension 32% 60% ICD Implant 4 31% 41% PCI 30% 54% PVI 5 20% 34%

27 Innovation: HealthPartners Low Risk Chest Pain Regions Hospital 90 ED Low risk chest pain patients OP Scheduled Eve & Weekends No Show Positive Stress-Cath ED Pt stress Mon - Fri 8 am - 5 pm Monthly Totals 10 0 OP Scheduled Eve & Weekends No Show Positive Stress-Cath ED Pt stress Mon - Fri 8 am - 5 pm Totals

28 30 Chest Pain Readmissions Decline Regions Hospital Readmissions

29 Low Risk Chest Pain Protocol - Success More than 2000 patients have benefited at Regions Hospital alone Safely avoided unnecessary care and benefited organization by $4 million dollars in rate alone HealthPartners shares these protocol with other participating providers to spread the benefits across the network Success of this program led to exploration of other low risk cardiac pathways

30 Low Risk Congestive Heart Failure

31 Low Risk CHF Protocol - Background AIM: create protocol to safely avoid hospitalizations/readmissions for low risk CHF patients through team approach involving ED, hospital medicine, and cardiology Hospital readmissions for CHF have historically been approximately 20% Affordable care act institutes penalties for CHF readmissions

32 Innovation: HealthPartners Low Risk Heart Failure Program Regions Hospital ED Presentation IV Diuretics ED Observation Meets low risk criteria Yes No Home Observation Next day CHF Clinic follow-up 1 week CHF Clinic Follow-up

33 Innovation: HealthPartners Low Risk Heart Failure Protocol Regions Emergency Department

34 Innovation: HealthPartners Low Risk Heart Failure Regions Hospital Protocol initiated in June 2012 and has led to change in ED care patterns ED trends from 2010 onward demonstrates a trend in higher utilization of observation and discharges to home after this protocol was initiated In 7 month period, 13 total 30-day inpatient admissions were saved 4 total 30-day inpatient admissions were saved by placing patients in observation 9 total 30-day inpatient admissions were saved by discharging patients to home Overall, this is a low risk population Only 7 of 59 patients were readmitted within 30 days

35 Heart Failure Volumes: Shift from Inpatient to Observation & Low-Risk Treatment 700 2% 100% % 21% 16 18% % 80% % % Cases 100% 50% % % 79% % 30% 20% % 20.62% 18.70% 18.65% 10% YTD Annualized Inpatient Observation Low Risk Heart Failure % Inpatient % Observation % Low Risk Heart Failure % Readmissions 0%

36 Low Risk Atrial Fibrillation

37 Low Risk Afib Protocol - Background 2.6 million people in US 2010 Prevalence projected to double 2020 Afib accounts for 1% of all ED visits in US 65% result in hospital admission 20% 30 day adverse outcome ED management varies greatly proclivity for cardioversion in patient with recent onset afib Spontaneous conversion to NSR in 70% patients with recent onset afib.

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39 Innovation: HealthPartners Low Risk Afib Program Regions Hospital

40 After Visit Summary Echo will be done next day at 10am Cardiology visit at 11:20am NPO after 7am except meds You may need a ride home

41 Atrial Fibrillation Volumes: Shift from inpatient to observation % 20% 28% 6% 21% 100% 90% 80% 70% C a e s % 50% % 80% 72% 73% 40% % 20% 50 10% YTD Inpatient Observation Low Risk Afibrillation Annualized % Inpatient % Outpatient % Low Risk Afibrillation 0%

42 Affordability Profile: Improving low risk cardiac care Summary of Success Reduced the number and rate of readmissions for chest pain & congestive heart failure patients Improved the experience of care for low risk cardiac patients Reduced the costs to patients and the system overall Shared learnings and benefits across all HealthPartners Networks

43 Questions & Discussion

44 Discussion What type of cost-reduction information from ACHP would be of the greatest value to you in 2015? What are new, ongoing or particularly innovative costreduction initiatives taking place at your plan? How are cost reduction strategies different for planemployed versus network physicians? How do your approaches either differ or align with those of UPMC and HealthPartners? 44

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