Getting Started with Bundled Payments for Orthopedics

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The webinar will provide a basic outline of a bundled payment model for total joint replacement or other orthopedic procedures, based on the experience at Hoag with real life examples of problems encountered and solutions created. The session will provide an overview of what to consider for process and contracting, including who should be involved in the development process and how to mitigate risk in the model.
About the Speaker:
Gabrielle White, RN, CASC, has over 23 years experience in the health care industry with a background in peri operative nursing and ASC administration. She is currently an Executive Director at Hoag Orthopedic Institute where she has clinical, business and administrative oversight of the Orthopedic Surgery Center of Orange County and leads Network Development for Hoag Orthopedic Institute with a primary focus on bundled payment programs and growth strategy with self-insured employers.

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Getting Started with Bundled Payments for Orthopedics

  1. 1. G A B R I E L L E W H I T E , R N . C A S C EXECUTIVE DIRECTOR AMBULATORY SERVICES & NETWORK DEVELOPMENT H O A G O R T H O P E D I C I N S T I T U T E C O N T I N U U M C A R E A D V I S O R S C C A D V I S O R S 1 @ G M A I L . C O M Getting Started with Bundled Payment for Orthopedics 1
  2. 2. Background 2   Hoag Orthopedic Institute [HOI] orthopedichospital.com / hoioutcomes.com   Orthopedic Surgery Center of Orange County [OSC] OSCOC.com   First global in 2008/09 - OSC   Global TPA – OSC   Global cash -OSC   Bundled pilot – HOI   Commercial bundle – HOI   > 250 global and bundled episodes
  3. 3. Our objectives 3   Create change in payment model   Improve care   Align providers   Provide value   Volume   Demonstrate success
  4. 4. Definition 4 A bundled payment is an all inclusive price that covers the cost of facility and professional services related to a specific procedure over a specified period of time that may or may not include a warranty
  5. 5. 5 $ Facility ProfessionalWarranty
  6. 6. Bundled example   Total knee arthroplasty   DRG 470   CPT – 27447   ICD – 81.54   Episode – admission > 90 days   Includes all care related to index procedure   Excludes – SNF, Home Health, care and procedures not related to index procedure, bilateral procedures Admission > discharge > post op care up to 90 days 6
  7. 7. Global example   Total knee arthoplasty   DRG 470   CPT – 27447   ICD – 81.54   Episode – admission > discharge   Includes all care related to index procedure during hospital stay   Excludes –care following discharge and procedures not related to index procedure, bilateral procedures Admission > discharge 7
  8. 8. 8 bundle team episode Manage risk Outcomespayers Claims monitor
  9. 9. Team   Team selection ¡  Clinical ¡  Administration ¡  Support services   Roles   Communication   Meetings   Reporting 9
  10. 10. Team Hospital/facility Coordinator / project lead – connect the dots   Physicians surgeon anesthesia Internist   Nursing   Administration Contracting Revenue cycle Benefits Registration 10
  11. 11. Team Professional Coordinator – liason with hospital   MD office lead Revenue cycle contracting benefits patient coordinator   Anesthesia   Internist   Other 11
  12. 12. Team Patient Communicate what why how when Educate 12
  13. 13. Episode 13   Procedure ¡  Predictable ¡  High volume ¡  Known cost ¡  Known outcomes   Included   Excluded   Time line   Warranty
  14. 14. Manage risk 14 Patient selection   Safe surgery   Health status ¡  BMI <38 ¡  ASA 1-2, 1-3 ¡  Medical history
  15. 15. Manage risk Providers   Volume   Quality   Outcomes   Cost 15
  16. 16. Warranty 16 ¡  Length ¡  Inclusions ¡  Exclusions ¡  Manage risk ¡  Provider data ¡  Self insured ¡  Re insurance ¡  Manage timeline
  17. 17. Outcomes   Quality benchmarks   Volume   ALOS   SSI   DVT/PE rate   Re admission   Claims 17
  18. 18. Manage cost   Reduce waste   Do what is necessary/best practice   Consider outcomes & risks   Know cost data per provider   Standardize   Work with vendors   Share savings 18
  19. 19. Payers   Commercial   Employers   Private pay 19
  20. 20. Payers   What do they want?   Payer roadblocks   Payer concerns   How will they benefit? 20
  21. 21. 21 Hospital Surgeon Anesthesia Other professional
  22. 22. 22 MD HospitalPayer
  23. 23. Claims   Align all providers   Pricing   Data   Who will manage claims?   Who will manage payments?   Process   Contract between providers   Risk pool? 23
  24. 24. Claims 24   Pre procedure   Post procedure/episode   One claim / multiple providers   One check / multiple providers   Coordination   Payer concerns
  25. 25. Communication Bundled alert! surgeon facility Other professional providers 25
  26. 26. Communication   Patients   Providers   Episode start > end   Outliers 26
  27. 27. Care redesign 27   Align providers   Claims management   Share risk   Standardize care ¡  Navigators ¡  Pre admission screening ¡  Infection prevention ¡  Transfusion rates ¡  Vendors
  28. 28. Provider contracting   Facility   Surgeon   Surgeon assistant   Anesthesiologist   Other ¡  Hospitalist ¡  Radiologist ¡  Pathologist ¡  Cardiologist 28
  29. 29. Benefits   Improve quality and outcomes   Reduce cost of care   Change from FFS   Payers/employers want ¡  Solutions & change ¡  Price predictability ¡  Reduced costs ¡  Risk sharing   Alignment   Share in savings & success 29
  30. 30. Early Road blocks   Communication   Payers   Providers   Knowing costs   Knowing data/outcomes   Process change   Risk sharing   Price setting   Claims management   Warranty   Risks 30
  31. 31. Monitoring success   Monthly reports ¡  Revenue cycle ¡  Performance improvement ¡  Peer review 31
  32. 32. Getting started 32 ¡  True & trusted leaders ¡  Payers ¡  Procedure ¡  Length of episode ¡  Warranty   Inclusion   exclusion ¡  Providers involved ¡  Data ¡  Rates ¡  Claims management ¡  Outcomes
  33. 33. Getting started   Cash global   Commercial global or bundled arrangement   Employer global or bundled arrangement   Consider a pilot   Start small 33
  34. 34.   Align providers   Build the team   Select high volume, predicable procedures   Patient selection criteria   Define the episode of care –start to finish, what it includes   Determine the bundle price, what it includes and excludes   Provider selection criteria   Define quality metrics to be met and monitored   Determine who will manage claims and payments   Identify interested payers   Educate   Monitor the program   Communication   Keep it simple In a nutshell
  35. 35. - THANK YOU! 35

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