Fundamentals of Bundles for Joint Replacement Creating the Competitive Edge

Maureen GearyProgram Manager

November 19, 2015

• Opened in July, 2007 and has performed over 21,000 cases to date.

• CJRI is the most profitable service line at Saint Francis Hospital.

• Saint Francis Hospital has a consulting agreement with Connecticut Joint Replacement Surgeons to manage CJRI.

• Surgeons and Anesthesiologists are in private practice

Connecticut Joint Replacement Institute (CJRI)

• The consulting agreement is a straight fee not a gain sharing model.

• Dedicated Space and Resources:

• 3 Floors

• 100 FTE (management, clinical, para professionals)

• Ancillary Services (Rehabilitation, Pharmacy, Housekeeping, Integrated Medicine)

Connecticut Joint Replacement Institute (CJRI)

The Step Ahead Program was established in 2010.

Three Participants:

1. Saint Francis Hospital & Medical Center

2. Connecticut Joint Replacement Surgeons

3. Woodland Anesthesia Associates

Bundle Program

Bundled Program Goals

Create a platform for care redesign to:

• Coordinate patient care

• Reduce variability

• Improve operational efficiencies

What is a “Bundled Payment”

“Single package price for a comprehensive and specific set of healthcare services delivered to a patient by multiple providers over a defined period of time (Episode)”

Essential Elements to Develop and Implement Your Bundle Program

Build a Multi Dimensional Team

• Administration and Physician Leadership

• Multidisciplinary Team

Legal

Finance

Clinical

Revenue Cycle

Operations

Define the Bundle

• Identify parties involved

• Define duties of each party

• Decide what is in/out

• Determine the timeframe

• Establish a warranty (if appropriate)

Duties of Each Party: Hospital

Provide the necessary infrastructure including:

• Facilities/ staff • Support services• Finance/Operations

Duties of Each Party: Surgeon

• Determine appropriateness for surgery

• Perform surgery

• Provide routine post-op in-patient care

• Adhere to guidelines and protocols

Duties of Each Party: Anesthesia

• Review eligibility and risk stratification

• Provide anesthesia services

• Adhere to best practice and protocols

Patient Criteria

• Patient under the age of 70 (non Medicare).

• Patients with either none or minimal systemic disease.

• 11 factors (BMI, major depression, chronic narcotic or alcohol dependency…)

• The criteria serves as guidelines and may be modified to the patient’s overall assessment.

Determine Cost

• Hospital• Surgeon• Anesthesia • Re-admissions and Complications

Define Quality Measures

• Re-admissions • Complications • HCAHPS scores• Length of Stay

Engage your Physicians

Each Orthopedic Surgeon and Anesthesiologist that performs bundle payment surgery will participate in an in-service that outlines in detail their specific responsibilities, the protocols/best practices, and their own personal financial risks for non-compliance.

Episode Starts

Episode Ends

Develop Care Maps

1. Commercial Payers

2. Center for Medicare Services

3. Large Self-Funded Employers

4. Third Party Administrators

5. Large Primary Care Groups

6. Un-(or under) insured patients

Identify Potential Buyers

• Bundle payment was an A + B + C model

• ½ of the patients were excluded from the bundle program due to anesthesia review

1st Commercial Contract

Challenges

• Reverted to manual systems and rework.

• Required additional resources across the board.

• Lack of integrated systems to process claims and payments.

• Hospital assumes the financial losses related to co- pays and retro eligibilities.

• Commercial payors are seeking to shift administrative tasks and risks to your bundle program while reducing overall payment.

• Promise steerage of patients to your organization.

Competing Priorities

Refining your Program

Physical Therapy Shift

• Patients admitted to the inpatient floor after 2 pm – only 20% ambulated.

• Develop a mobility technician program.

• Recalibrate certified nursing assistant and mobility tech role into one role

Patient Ambulation - Mobility Program July – August

Post OpDay

Staff Type Ambulating the Patient Percentage Average Times Patient

Ambulated

0

Mobility Techs, Nursing Assistants and Registered Nurses 93%

2.1

Physical Therapy 7%

1Mobility Techs, Nursing Assistants and Registered Nurses 61%

4.6

Physical Therapy, Physical Therapy Assistant 39%

2Mobility Techs, Nursing Assistants and Registered Nurses 60%

4.2

Physical Therapy, Physical Therapy Assistant 40%

Case Management

• Clinical oversight of patients should be only for those going to an extended care facility (less than 20% of patients)

• Shift work required to a highly skilled administrative assistant

• Post acute spend was approximately $4,200

• Collaborating with post acute providers

Reference Based Model• Desired Outcomes

• Metrics and Measurement

Changing the Paradigm Post Acute Care

Third Party Administrators New Book of Business

• Third party administrators are representing the employers

• Seeking regional centers of excellence

Three Models

• Episode with the hospital stay

• Episode with readmissions

• Episode with post acute services

Things to Consider

• Who is in control?

• New way of doing business (telemedicine)

• Assume readmissions for patients that are readmitted outside your network

• Assume costs for patients that don’t behave

Evolution of Our Bundle Payment 2009 Formation of a multi-disciplinary team to explore

bundled payment programs

2010 Bundle Program was established

2012 Signed a bundled contract with Payor

2013 Partnership with Harvard Business School. Project lead with 30 organizations on Time Driven Activity Based Costing (TDABC).

2015 5 national contracts as regional center of excellence

Creating a Competitive Edge

• Physician Leadership and Administration are essential

• Know your value

• Evolving and Refining your business model

Questions

Thank You

35

Streamlining Orthopedic Episodes of Care

www.wellbe.me

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Seeking Speakers

OrthoServiceLine offers a $500 speaking honorarium for a 45-minute webinar and 15 minute Q&A from your desktop and phone.

We are currently seeking speakers for our 2016 webinar series.

Interested? Send an email to ortho@wellbe.me.

Also seeking speakers for our next LIVE MSK Leadership Summit – Tentatively March 30 in NYC!