This presentation discusses how health care organizations can use episodes of care to change medical practice. An episode of care is defined as all services related to a clinical event from pre-operation through recovery. Analyzing costs and variations in services provided within episodes can reveal opportunities for improvement and standardized care pathways. Episode data attributes services to managing providers and compares actual costs to risk-adjusted benchmarks in order to identify potentially avoidable utilization and complications.

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How Health Care Organizations Can Use Episodes of Care
to Change the Practice of Medicine
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NCHICA 20th Annual Conference & Exhibition | October 7, 2014
Deidra Peacock, MBA, CPHIMS | SAS Institute, Inc.

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A New Unit of Analysis: Clinical Episodes
Copyr ight © 2014, SAS Institute Inc. All rights reser ved.
NCHICA 20th Annual Conference & Exhibition | October 7, 2014
Deidra Peacock, MBA, CPHIMS | SAS Institute, Inc.

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A NEW UNIT OF ANALYSIS
Intermountain Healthcare… is neither taking bundled payments nor
building an accountable care organization. But to achieve its strategic goal
of “shared accountability” with payers and patients, [we are] focusing on
reducing variations in care. And to do that… “we think the right unit of
analysis is at the episode level.”
~Gregory Poulsen
Senior Vice President and Chief Strategy Officer
Intermountain Healthcare
White paper: Episode Analytics: Essential Tools for New Healthcare Models, Institute for Health Technology Transformation, 2014.

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CLINICAL EPISODES A NEW UNIT OF ANALYSIS
• What is a clinical episode?
• Why do episodes matter today?
• How do episode variations provide insight?
• What are the differences between actual and risk adjusted care?
• How does it all work?

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CLINICAL EPISODES WHAT IS A CLINICAL EPISODE?
Fee-for-Service Value-Based Payment

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CLINICAL EPISODES PROFESSIONAL SERVICES

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CLINICAL EPISODES ADD HOSPITAL / OTHER SERVICES

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CLINICAL EPISODES ADD HOSPITAL / OTHER SERVICES

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CLINICAL EPISODES ADD PHARMACY

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CLINICAL EPISODES ANATOMY OF A CLINICAL EPISODE
PRE-OP HOSPITALIZATION POST-OP
HIP PROCEDURE RECOVERYDIAGNOSIS/TESTING
Typical
READMISSION (INFECTION)
Complication
OUTPATIENT CATHDOCTOR VISITS
Unrelated

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CLINICAL EPISODES WHAT IS A CLINICAL EPISODE?
true dollars &
components of
episodes
potentially
avoidable
complications
accountability
and
comparisons
episode
definition

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CLINICAL EPISODES QUESTIONS THAT CAN BE ANSWERED
For which episodes of care do we
perform best?
What under and overutilization do
we have in chronic care?
What are our main drivers of
potentially avoidable
costs/complications?
Where are the greatest
opportunities for improvement?
Should we participate in bundled
payment contracts?
What is a reasonable level of
shared savings for the upcoming
year?
What clinical groups are
represented in my population and
how well are we treating them?
Where are my costs going if I do
nothing?

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EPISODE
COMPONENTS
FULL EPISODE FOR “ROUTINE” HIP REPLACEMENT
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
THE SIGNALING EVENT
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility Facility
Pre-opLabs
Wound
InfectionMD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology
MD-Anesthesia
MD-Ortho
ImagingMRI
OR&Implant
PostOpLabs

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EPISODE
COMPONENTS
SIGNALING EVENT INCLUDING PROFESSIONAL SERVICES
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
EPISODE WITH JUST PROFESSIONAL SERVICES
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
SUBSEQUENT ADMISSIONS
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
POST SIGNAL SERVICES
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
ATTRIBUTED PROVIDER
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
Facility
MD-Ortho
Facility
Wound
Infection
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Pre-opLabs
ImagingMRI
OR&Implant
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
UNDERSTAND RELEVANT SERVICES / DOLLARS
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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EPISODE
COMPONENTS
DISTINGUISH TYPICAL AND COMPLICATION DOLLARS
1 Month
Pre Op
Surgery Readmit
1 Month
Post Op
2 Month
Post Op
MDPCP
MD-Ortho
MD-Cardiology
ImagingMRI
Facility
MD-Ortho
ImagingMRI Facility
OR&Implant
Pre-opLabs
Wound
Infection
MD-Anesthesia
PostOpLabs
MD–ED
MDPCP
EDLabs
MD–Hospitalist
ImagingX-Ray
MD-Ortho
RX-Antibiotics
MDPCP
MDPCP
MD-Cardiology

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SO WHAT? STUFF WE KNOW WITH EPISODIC SERVICE DETAIL
• Variation in services performed / care patterns
• Comparison to standards/best practices
• Variation in cost/revenue
• Repeated services, e.g. waste
• Core services for chronic care
• Utilization of providers and assets
• Attributed provider vs. rendering provider or service location

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SO WHAT? IDENTIFYING POTENTIALLY AVOIDABLE CARE VARIATION
Volume of Episodes
UtilizationPerEpisode
Diabetes
Hip & Knee
Replacement
CHF
AMI
Colonoscopy
Spine
Surgery
Bariatric
Surgery
CABG
Asthma
Gall Bladder
Surgery

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CLINICAL EPISODES ASSOCIATIONS ARE COOL
$$$$
$$$$ $
$

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CLINICAL EPISODES COMPARING DOLLARS
• Actual Dollars Paid
• IP claim, OP/Prof service
• Split claim, split service
• Typical vs complication
• Risk Adjusted
• Patient severity – 6 months prior
• Episode-specific – signaling event
• Typical and complication

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CLINICAL EPISODES ACTION POINTS
1. Go beyond traditional episode groupers
2. Start with claims data
3. Attribute episodes to the correct managing provider
4. Analyze variations in episodes of care
5. Measure adherence to evidence-based practice guidelines
6. Use the data to collaborate
White paper: Episode Analytics: Essential Tools for New Healthcare Models, Institute for Health Technology Transformation, 2014.

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A PARADIGM SHIFT
“[Bundled payments are] really a step towards the paradigm shift to the
standardization of care: protocols, pathways, and the reasons for variation. For
us to be operationally excellent, we have to be able to decrease process
variation, and this is a mechanism to get us there.”
~Tricia Nguyen, MD
President, Texas Health Resources Population Health, Education & Innovation Center
White paper: Episode Analytics: Essential Tools for New Healthcare Models, Institute for Health Technology Transformation, 2014.

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QUESTIONS?

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