Linking the Clinical & Business Successes of Patient Blood Management

Transcription

1 Linking the Clinical & Business Successes of Patient Blood Management Randy Henderson, Program Director Alexander Pérez, Program Coordinator Transfusion-Free Surgery & Patient Blood Management

2 Conflict of Interest Disclosure Randy Henderson and Alexander Pérez Has no real or apparent conflicts of interest to report.

3 About Keck Medical Center of USC 600 plus faculty, 18 plus specialty practices Outpatient sites located in Downtown LA, San Gabriel Valley, West LA, and at USC University Park Campus 411-bed inpatient tertiary & quaternary acute care facility with intense surgical inpatient population USC Care Medical Group Ambulatory Sites & Services Keck Hospital of USC Keck Medical Center of USC USC Verdugo Hills Hospital Built exclusively for cancer research and patient care, USC Norris Cancer Hospital is a 60-bed inpatient facility providing acute and critical care USC Norris Cancer Center & Hospital Recently acquired 158-bed acute care hospital, provides a full range of emergency, primary medical and surgical inpatient services, and diagnostic services

4 Keck Medical Center of USC Case Mix Index The CMI of a hospital reflects the clinical complexity and the needs for resources in the population of all the patients in the hospital hospitals included 3600 Hospitals Average CMI is 1.37 Range from.58 to 3.73 Standard deviation of 0.31 Most Recent FY: KMC Case Mix Index (CMI) is 2.68 Tertiary, Quaternary in terms of CMI, Specialty Surgery & Blood Loss

5 Global Impact of Transfusion Free Programs Blood products and transfusion represent significant expense to hospitals. FY13, blood product spend ~ 5% of supply expenses On average, blood product charges ~ 2.5% of all charges during an inpatient stay Clinical evidence reveals that transfusion-free strategies and technology may have a positive impact on healing and enhance the recovery process. Reduces the chance of post-operative infection Eliminates the risk of allergic reaction /complication from transfused blood Pay-for-performance reimbursement models require health care systems to contain current costs without compromising quality of care By avoiding transfusions, patients and third-party payors do not have to deal with the rising costs of blood products.

6 Financial Impact of Transfusion Free Do we observe a financial impact when comparing our transfusion free patient population to all other patients at Keck Medical Center of USC? Sampled Transfusion Free (TF) Inpatients: Jehovah Witness inpatients Discharged between July 1, 2009 June 30, 2013 Method of Analysis: Comparative analysis between JW inpatients and all other inpatients discharged between FY10 FY13 o Length of Stay o Case Mix Index (patient acuity level) o Total Net Revenue o Total Variable Cost per Inpatient Case

7 Patient Demographics Favorable inpatient payor mix when compared to overall inpatient payor mix at Keck Medical Center of USC TF Payor Mix vs. TF Inpatient Case Volume FY10 FY13 Total I/P Cases Medicare Managed Care Medicaid Other % % 80% 70% Inpatient Cases % 41% 48% 34% 45% 36% 41% 60% 50% 40% 30% Payor MIx (%) 40 15% 17% 16% 20% 20 6% 3% 2% 2% 10% 0 FY10 FY11 FY12 FY13 0%

8 Notes on Comparative Analysis 15 DRG-Based Triads represent to focus of the comparison (based on JW inpatient case volume) Triads combine similar DRGs (Diagnostic Related Groups) o Example, Triad-141 Major Lower Extr. Joint Replacement combines data for: o DRG-469, Major Joint Replacement Or Reattachment of Lower Extremity W MCC o DRG-470, Major Joint Replacement Or Reattachment of Lower Extremity W/O MCC We assume that all JW inpatients did not receive transfused blood products during their inpatient visit (confirmed by no blood charges) While Top 15 DRG-Based Triads are based on the greatest number of JW inpatient cases, the JW inpatient volume does not reflect a significant sample size and thus the findings can only at this time be considered for observation

9 Comparative Analysis Overall, we observe that JW inpatients average a lower Length of Stay; in addition to CMI. Adjusting the ALOS to account for CMI reveals that the delta in LOS favors all other inpatients DRG-Based Triad Triad Description Total Inpt. Case Volume Avg. Length of Stay Avg. Case Mix Index CMI Adjusted Length of Stay JW All Other JW All Other Delta JW All Other Delta JW Other Delta Triad-141 Major Lower Extr. Joint Replacement 36 1, Triad-106 Major Small & Lrg Bowel Procedure Triad-62 Respiratory Infections Triad-125 Pancreas, Liver & Shunt Procedures Triad-105 Stomach, Esophageal & Duodenal Procedures 17 1, Triad-198 Kidney & Ureter Procedures 16 1, Triad-123 Esophagitis, GI & Misc Digestive Disorders Triad-188 O.R. Procedures for Obesity Triad-226 Uterine & Adnexa Proc Triad-130 Cirrhosis Triad-77 Cardiac Valve & Other Major CV Proc 10 1, Triad-214 Major Male Pelvic Procedure 10 1, Triad-251 Postoperative Infections Triad-15 Craniotomy Endovascular Triad-114 Other Digestive System O.R. Procedures Grand Total ,

10 ALOS & CMI Comparison Average length of stay and CMI comparison between transfusion free inpatients versus all other inpatients between FY10 and FY13 TF vs. All Other Inpatients FY10 - FY13 TF ALOS All Other ALOS TF CMI All Other CMI FY10 FY11 FY12 FY

11 Case Mix Index However, a higher CMI is observed in our all other patient population ( overall). Further justification for the observed increased Total Net Revenue per inpatient case TF vs. All Other Inpatients FY10 - FY13 TF All Other

12 Average Length of Stay Overall, we observe that TF inpatients in the Top 15 DRG-based Triads average a lower length of stay compared to all other inpatients (1 day). TF vs. All Other Inpatients FY10 - FY13 TF All Other

13 CMI Adjusted LOS Adjusting the average length stay to account for patient acuity yields a comparison favorable to TF inpatients for the Top 15 DRG-based Triads. TF vs. All Other Inpatients FY10 - FY13 TF Other

14 Comparative Financial Analysis Overall, we observe that total variable costs are less for TF patients by $623 per inpatient case when adjusting variable cost for patient acuity. DRG-Based Triad Triad Description Total Inpt. Case Volume CMI Adjusted Length of Stay CMI Adjusted Avg. Variable Cost per Case JW All Other JW Other Delta JW Other Delta Triad-141 Major Lower Extr. Joint Replacement 36 1, $ 9,577 $ 9,727 $ (150) Triad-106 Major Small & Lrg Bowel Procedure $ 8,373 $ 8,279 $ 93 Triad-62 Respiratory Infections $ 11,433 $ 14,709 $ (3,276) Triad-125 Pancreas, Liver & Shunt Procedures $ 7,837 $ 9,032 $ (1,195) Triad-105 Stomach, Esophageal & Duodenal Procedures 17 1, $ 8,820 $ 10,716 $ (1,896) Triad-198 Kidney & Ureter Procedures 16 1, $ 8,314 $ 9,639 $ (1,325) Triad-123 Esophagitis, GI & Misc Digestive Disorders $ 7,119 $ 8,587 $ (1,468) Triad-188 O.R. Procedures for Obesity $ 8,057 $ 7,908 $ 150 Triad-226 Uterine & Adnexa Proc $ 8,281 $ 9,742 $ (1,461) Triad-130 Cirrhosis $ 4,991 $ 11,866 $ (6,875) Triad-77 Cardiac Valve & Other Major CV Proc 10 1, $ 5,688 $ 6,650 $ (963) Triad-214 Major Male Pelvic Procedure 10 1, $ 6,811 $ 7,635 $ (824) Triad-251 Postoperative Infections $ 5,673 $ 9,404 $ (3,731) Triad-15 Craniotomy Endovascular $ 5,208 $ 7,367 $ (2,159) Triad-114 Other Digestive System O.R. Procedures $ 7,951 $ 10,587 $ (2,635) Grand Total , $ 7,882 $ 8,505 $ (623)

15 Revenue Analysis Overall, 918 TF patients were seen over the past 4 fiscal years. 44% of outpatients converted to an inpatient visit, 29% of which had two or more inpatient encounters. Transfusion Free Revenue Analysis Total Net Revenue vs. Volume Inpt. TF Cases Outpt. TF Visits Inpt. TF Tot Net Rev Outpt. TF Tot Net Rev $5,000,000 $4,500,000 $4,000,000 $3,500,000 $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $- 2,568 2,380 1, FY10 FY11 FY12 FY

16 Revenue Analysis A macro level analysis of fiscal year 2013 Total Net Revenue per case/visit for transfusion free patients compared to all other patients reveals a negative delta reveals the following: FY13 Metric Inpatient Outpatient TF All Other Delta TF All Other Delta Rev per Case/Visit $ 32,846 $ 44,766 $ (11,920) $ 1,088 $ 883 $ 205 Profit Margin % 33% 41% -8% 41% 38% 3% Analysis of Findings: Higher CMI (patient acuity level) for all other inpatients drives increased revenue inpatient case TF smaller patient sample size and the possibility of a higher utilization % for outpatient procedures drives increased revenue delta per outpatient visit * Profit Margin = (Total Net Revenue Tot Var Cost)/ Total Net Revenue, excludes any additional fixed/overhead costs

17 Comparative Resource Use Analysis Total inpatient case volume per DRG-based Triad from FY10-FY13, Top 15 account for 40% of JW inpatient cases. DRG-Based Triad Triad Description TF All Other Utilized Blood Case % Avg. Blood Spend per Case % of Total Variable Triad-141 Major Lower Extr. Joint Replacement 36 1,406 25% $ % Triad-106 Major Small & Lrg Bowel Procedure % $ 1, % Triad-62 Respiratory Infections % $ % Triad-125 Pancreas, Liver & Shunt Procedures % $ 2, % Triad-105 Stomach, Esophageal & Duodenal Procedures 17 1,246 26% $ 1, % Triad-198 Kidney & Ureter Procedures 16 1,016 25% $ 2, % Triad-123 Esophagitis, GI & Misc Digestive Disorders % $ % Triad-188 O.R. Procedures for Obesity % $ % Triad-226 Uterine & Adnexa Proc % $ % Triad-130 Cirrhosis % $ 2, % Triad-77 Cardiac Valve & Other Major CV Proc 10 1,314 83% $ 4, % Triad-214 Major Male Pelvic Procedure 10 1,143 3% $ 1, % Triad-251 Postoperative Infections % $ 1, % Triad-15 Craniotomy Endovascular % $ 1, % Triad-114 Other Digestive System O.R. Procedures % $ 1, % Grand Total Total Inpt. Case Volume 'All Other' Blood Spend Stats Cost ,725 26% $ 2, %

18 Comparative Cost Analysis Adjusting variable cost per case for patient acuity, we observe that total variable costs are on average less for TF patients by $623 per inpatient case when comparing patients within the Top 15 DRG-based Triads. TF vs. All Other Inpatients FY10 - FY13 TF Other $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $-

19 Next Steps The comparative analysis has led us to broadly observe a variable cost savings between transfusion free patients compared to all other inpatients within 15 DRG-Based Triad patient populations. Increase our sample size of transfusion free inpatients so that findings may be considered statistically significant Integrate quality and outcomes data to further rationalize our observation.

20 Rigorous Resource Use Analysis Blood utilization by service line Anesthesiologist and ANH utilization Surgeon and Blood loss in cases Surgeon & Cell Saver/ANH & Blood Loss Pre-op anemia by service line and surgeon Transfusion guideline adherence by surgeon/anesthesiologist Pre-operative use of the Anemia Management Program- Service Line, Physician for elective surgery

21 The Business Case: Geographic Market Jehovah Witness ( JW) inpatients represent the vast majority of our transfusion free patient population 1.4% of total inpatient volume between FY10 and FY13 (574 total inpatient encounters) Favorable payor mix, overall 38% carry managed care/commercial health insurance Majority of JW inpatients reside in California with increasing number coming from outside CA. Geographical Breakdown of Patient Population - Overall vs. JW inpatients IP Vol as a % of Keck's State Total US Vol. CA 96.4% NV 1.3% AZ 0.4% HI 0.2% TX 0.2% OR 0.2% CO 0.1% FL 0.1% WA 0.1% NM 0.1% City Inpatient JW City's IP Vol as a % of Inpatient JW State's IP Vol as a % of State Vol. Total CA IP Vol. Vol. Total US Vol. LOS ANGELES % NV % BAKERSFIELD % AZ % PALMDALE 9 0.9% FL 3 3.3% WHITTIER 8 2.0% KY 2 0.3% LANCASTER 7 1.2% TX 2 4.4% COMPTON 6 0.4% OR 2 3.9% COVINA 6 1.1% MT 2 1.0% LONG BEACH 6 1.9% AR 1 0.5% RIVERSIDE 6 0.5% NY 1 2.1% ALHAMBRA 5 1.2% CO 1 3.4% BALDWIN PARK 5 0.6% MONTEBELLO 5 1.1% OXNARD 5 0.8%

22 The Business Case Market Differentiation Regional Presence Core to Tertiary/ Quaternary Service Academic Mission

23

24 Special Thanks to Tarek Salaway & Tyler Woolsey THANK YOU!