Transcript Leveraging Lessons Learned from the BPCI

Helping Hospitals
Understand and Embrace
Bundled Payments
Gloria Kupferman, Vice President, DataGen
Kelly Price, Director, DataGen Group
A2HA
March 20, 2013
Key Lessons
• Data is king, be ready to deal with large
amounts of it
• Know the game and why you’re playing
• Fill all positions on the team
• Understand variation, risk and opportunity
• There’s a difference between reducing costs at
the provider level and reducing costs for the
payer (program costs)
Remember the Payer’s POV
Dr.
Office
Visit
Initial
Inpatient
Stay
Dr.
Office
Visit
Dr.
Hospital
Visit
Dr.
Hospital
Visit
Readmission
Dr.
Hospital
Visit
Dr.
Hospital
Visit
Dr.
Office
Visit
Inpatient
Post-Acute
Stay (Rehab,
Psych, LTC,
SNF, HH)
Other Part B Services
(Hospital Outpatient,
Labs, Durable Medical
Equipment, Part B
Drugs)
Metrics
• Must support decision-making
– Focus on decision-making and application
– Avoid interesting but useless information
• Must be understandable
• Can’t be static
• Here’s how we analyzed the Medicare
BPCI data:
Analytic Decision Drivers
• Volume – i.e. critical mass
• Payment variation
• Discernible, manageable care
patterns
• Benchmark comparisons
Identify Episodes of Interest
Total Payments vs Coefficient of Variation by Core DRG for
90-Day Episodes
$9,000,000
$8,000,000
$7,000,000
Total Payments
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
20
40
60
80
100
Coefficient of Variation
120
140
160
180
Episodes of Interest
Core DRGs of Interest
Core
DRG
23
60
65
66
73
79
86
88
91
97
99
101
104
108
110
111
114
Coefficient
Description
Volume of Variation
Intracranial hemorrhage or
136
80.13
cerebral infarction
Respiratory infections &
65
104.30
inflammations
Chronic obstructive pulmonary
207
83.94
disease
Simple pneumonia & pleurisy
180
105.87
Respiratory system diagnosis w
43
110.23
ventilator support <96 hours
Cardiac defibrillator implant w/o
27
56.78
cardiac cath
Permanent cardiac pacemaker
51
69.16
implant
Percutaneous cardiovascular proc
85
70.99
w drug-eluting stent
Other vascular procedures
70
70.91
Acute myocardial infarction,
52
94.50
discharged alive
Circulatory disorders except AMI,
95
118.89
w card cath
Heart failure & shock
274
97.13
Peripheral vascular disorders
65
100.22
Cardiac arrhythmia & conduction
155
107.89
disorders
Syncope & collapse
126
119.54
Chest pain
124
130.33
Major small & large bowel
62
66.01
procedures
Total
Payments
$ 3,137,624
$ 1,744,818
$ 3,317,440
$ 2,610,624
$ 1,341,852
$ 1,109,432
$ 1,182,165
$ 1,567,558
$ 1,225,372
$ 1,300,436
$ 1,553,682
$ 4,671,017
$ 1,132,814
$ 2,116,235
$ 1,485,878
$ 1,173,151
$ 2,199,797
Evaluate Payment Variation
Within Bundles
Where is the variation?
Remember the payer’s POV.
Start thinking in terms of potentially preventable costs (to the payer).
Target Hospital Total Anchor Payments and Total Post Anchor Payments
Total Payments per Episode
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
Anchor Admission Payments
Post Anchor Payments
Regional Average
Regional Outlier Threshold
Cost Composition and Variation
Initial Inpatient Stay
Initial Admission Payments by Care Type
IPPS DRG Pymt
Physician
Outpatient
Dur Med Equip
What’s happening
within the hospital?
4965769712
4914461122
4875206431
Identify outliers and
short stays.
4837664211
4810789561
Episode ID
1907318131
1899623121
Identify variation in
physician care.
1895668802
1892399573
1876573221
1870169721
Are all these patients
the same?
1863488471
1846199801
1807140903
1025590813
$-
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Cost Composition and Variation
90 Days Post Initial Stay
Post-Initial Payments by Care Type
Readmission
Physician
Rehab
Outpatient
Outpatient in Readmit
Home Health
Dur Med Equip
Dur Med Equip in Readmit
Skilled Nursing Facility
What happens after the
patient leaves the hospital?
4965769712
Identify readmissions.
4914461122
4875206431
See hand-offs to post-acute
settings.
4837664211
4810789561
Episode ID
1907318131
1899623121
Find sources of variation.
1895668802
1892399573
What is potentially
preventable?
1876573221
1870169721
1863488471
1846199801
Where is the potential for
standardization?
1807140903
1025590813
$-
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
Physician Claims by Specialty
4965769712
What physician specialties are
predominant?
4914461122
4875206431
4837664211
Who do we need to align with?
4810789561
1907318131
How do services vary? Why?
1899623121
1895668802
Do the patterns make sense?
1892399573
Is the variation due to lack of
coordination?
1876573221
1870169721
1863488471
1846199801
1807140903
1025590813
$0
$1,000
$2,000
$3,000
$4,000
$5,000
Pricing Comparisons
Are the volumes in other hospitals
high enough to be reliable?
What do my neighbors look like?
Episode Averages for All Hospitals Within Region
Average Payments per Episode
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
Comparison Hospital Volume<10
Comparison Hospital Volume >10 <50
Compraison Hospital Volume>50
Target Hospital Volume = 15
Regional Average
Outlier threshold
Pricing Comparisons
What components do I
need to include in my price?
How does my price compare
to benchmark?
Where am I different and
why?
Hospital
Average
Benchmark
# of
Episode
Episodes
Price
Initial Admission
354
Average #
Claims Per
Episode
$31,480
Referral Region
Average
Average
Average
Benchmark Benchmark
Benchmark
Payment per Payment per
# of
Episode
Claim
Episode
Episodes
Price
$12,047
Average #
Claims Per
Episode
$12,047 9,576 $32,598
Average
Average
Benchmark Benchmark
Payment per Payment per
Claim
Episode
$11,586
$11,586
Readmission
0.19
$7,982
$1,488
0.33
$7,481
$2,468
Inpatient Rehab
0.60
$10,110
$6,026
0.34
$11,107
$3,789
Home Health Care
0.87
$3,084
$2,684
0.67
$2,949
$1,978
SNF
0.45
$6,700
$3,047
0.99
$6,654
$6,570
LTCH
0.01
$31,772
$269
0.00
$29,975
$106
Physician Inpatient
20.63
$149
$3,080
25.97
$129
$3,357
Physician Non Inpatient
58.72
$40
$2,349
52.98
$39
$2,049
OPD Inpatient
0.01
$241
$2
0.08
$195
$16
OPD Non Inpatient
1.52
$207
$315
1.73
$288
$500
DME Inpatient
0.29
$45
$13
0.22
$67
$14
DME Non-Inpatient
2.45
$65
$159
2.18
$75
$165
First Post-Anchor Site of Care
Post-Anchor Payment
No Institutional
Care
HHA
SNF
LTCH
IRF
Readmission
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
Regional Variation
AMI
Readmission
HHA
SNF
Inpatient Rehab
Manhattan
Newark-White Plains
38%
31%
28%
2%
45%
17%
35%
1%
Major Joint – Lower Extremity
Readmission
HHA
SNF
Inpatient Rehab
Manhattan
Newark-White Plains
14%
14%
41%
32%
11%
50%
1%
23%
Readmissions Drive Costs
Without readmits
# Episodes
MAJOR JOINT REPLACEMENT OR
REATTACHMENT OF LOWER
EXTREMITY W/O MCC
1,531
Total Episode
Price
# Episodes
Total Episode
Price
$32,817
530
$41,943
Without readmits
ACUTE MYOCARDIAL INFARCTION,
DISCHARGED ALIVE W MCC
Episodes with a readmission
Episodes with a readmission
# Episodes
Total Episode
Price
# Episodes
Total Episode
Price
289
$24,637
305
$50,569
Readmissions Drive Costs
Distribution of Readmissions: Hospital (n= 6) Region (n=38)
100%
90%
80%
70%
60%
30-90 Days
50%
15-29 Days
40%
8-14 Days
30%
1-7 Days
20%
10%
0%
Hospital Readmissions
Readmission
DRG
251
313
812
287
247
251
Description
PERC CARDIOVASC PROC W/O CORONARY
ARTERY STENT W/O MCC
CHEST PAIN
RED BLOOD CELL DISORDERS W/O MCC
CIRCULATORY DISORDERS EXCEPT AMI, W
CARD CATH W/O MCC
PERC CARDIOVASC PROC W DRUG-ELUTING
STENT W/O MCC
PERC CARDIOVASC PROC W/O CORONARY
ARTERY STENT W/O MCC
Regional Readmissions
Days from Anchor
Discharge
Readmission
Dollars
Readmission
Dollars % of Total
Episode Price
Total
Episode
Price
74
$8,917
40.2%
$22,157
22
83
$2,954
$4,242
19.2%
17.7%
$15,400
$23,965
25
$5,701
30.2%
$18,881
25
$10,635
44.8%
$23,756
70
$8,917
40.8%
$21,835
Where is the volume. . .
Episode Category
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Esophagitis, gastroenteritis and other digestive disorders
Urinary tract infection
Stroke
Renal failure
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Esophagitis, gastroenteritis and other digestive disorders
Urinary tract infection
Stroke
Renal failure
Gastrointestinal hemorrhage
Percutaneous coronary intervention
Other respiratory
Medical non-infectious orthopedic
Nutritional and metabolic disorders
Cellulitis
Hip & femur procedures except major joint
Syncope & collapse
Acute myocardial infarction
Chest pain
Major bowel procedure
Red blood cell disorders
Gastrointestinal obstruction
Transient ischemia
Pacemaker
Other vascular surgery
Medical peripheral vascular disorders
Diabetes
Spinal fusion (non-cervical)
Coronary artery bypass graft
Back & neck except spinal fusion
Major cardiovascular procedure
Lower extremity and humerus procedure exept hip, foot, femur
Cardiac valve
Cervical spinal fusion
Fractures of the femur and hip or pelvis
Revision of the hip or knee
Major joint replacement of the upper extremity
Atherosclerosis
Cardiac defibrillator
Amputation
Removal of orthopedic devices
Double joint replacement of the lower extremity
Other knee procedures
Pacemaker device replacement or revision
Combined anterior posterior spinal fusion
Complex non-cervical spinal fusion
AICD generator or lead
Total Count
239,157
227,387
215,562
168,243
152,902
121,665
120,370
119,282
104,418
98,276
91,852
91,463
86,778
82,606
80,962
71,813
64,807
62,679
57,093
55,116
54,294
48,290
46,628
39,464
37,641
36,369
36,013
35,842
35,809
28,964
28,143
23,674
23,617
22,906
20,220
19,852
19,163
18,044
16,726
14,061
12,653
5,769
5,515
5,206
4,455
3,990
3,070
1,588
Total count from episode totals file
239,726
227,555
216,070
168,811
153,307
121,934
120,570
119,667
104,648
98,585
Where is the volume. . .
Episode Category
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Episode Category
Esophagitis,
gastroenteritis
and other
disorders
Major
joint replacement
ofdigestive
the lower
extremity
Urinary tract
infection
Simple
pneumonia and respiratory infections
Stroke
Sepsis
Renal failure
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Esophagitis, gastroenteritis and other digestive disorders
Urinary tract infection
Stroke
Renal failure
Gastrointestinal hemorrhage
Percutaneous coronary intervention
Other respiratory
Medical non-infectious orthopedic
Nutritional and metabolic disorders
Cellulitis
Hip & femur procedures except major joint
Syncope & collapse
Acute myocardial infarction
Chest pain
Major bowel procedure
Red blood cell disorders
Gastrointestinal obstruction
Transient ischemia
Pacemaker
Other vascular surgery
Medical peripheral vascular disorders
Diabetes
Spinal fusion (non-cervical)
Coronary artery bypass graft
Back & neck except spinal fusion
Major cardiovascular procedure
Lower extremity and humerus procedure exept hip, foot, femur
Cardiac valve
Cervical spinal fusion
Fractures of the femur and hip or pelvis
Revision of the hip or knee
Major joint replacement of the upper extremity
Atherosclerosis
Cardiac defibrillator
Amputation
Removal of orthopedic devices
Double joint replacement of the lower extremity
Other knee procedures
Pacemaker device replacement or revision
Combined anterior posterior spinal fusion
Complex non-cervical spinal fusion
AICD generator or lead
Total Count
239,157
227,387
215,562
168,243
152,902
121,665
120,370
119,282
104,418
98,276
91,852
91,463
86,778
82,606
80,962
71,813
64,807
62,679
57,093
55,116
54,294
48,290
46,628
39,464
37,641
36,369
36,013
35,842
35,809
28,964
28,143
23,674
23,617
22,906
20,220
19,852
19,163
18,044
16,726
14,061
12,653
5,769
5,515
5,206
4,455
3,990
3,070
1,588
Total count from episode totals file
239,726
227,555
216,070
168,811
153,307
Total dollars from
121,934 Total count from
episode
episode
totalstotals
file f
120,570
227,555
6,482,019,352
119,667
239,726
5,593,890,331
104,648
153,307
5,133,428,557
98,585
Congestive heart failure
Chronic obstructive pulmonary disease, bronchitis, asthma
Stroke
Hip & femur procedures except major joint
Urinary tract infection
Other respiratory
Renal failure
168,811
216,070
104,648
64,870
119,667
87,062
98,585
4,272,114,613
4,188,074,871
3,458,555,300
3,019,637,592
2,886,143,337
2,859,854,067
2,562,273,347
Are we done yet?
Episode Category
Amputation
Hip & femur procedures except major joint
Lower extremity and humerus procedure exept hip, foot, femur
Coronary artery bypass graft
Cardiac valve
Fractures of the femur and hip or pelvis
Medical non-infectious orthopedic
Stroke
Urinary tract infection
Removal of orthopedic devices
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Esophagitis, gastroenteritis and other digestive disorders
Urinary tract infection
Stroke
Renal failure
Gastrointestinal hemorrhage
Percutaneous coronary intervention
Other respiratory
Medical non-infectious orthopedic
Nutritional and metabolic disorders
Cellulitis
Hip & femur procedures except major joint
Syncope & collapse
Acute myocardial infarction
Chest pain
Major bowel procedure
Red blood cell disorders
Gastrointestinal obstruction
Transient ischemia
Pacemaker
Other vascular surgery
Medical peripheral vascular disorders
Diabetes
Spinal fusion (non-cervical)
Coronary artery bypass graft
Back & neck except spinal fusion
Major cardiovascular procedure
Lower extremity and humerus procedure exept hip, foot, femur
Cardiac valve
Cervical spinal fusion
Fractures of the femur and hip or pelvis
Revision of the hip or knee
Major joint replacement of the upper extremity
Atherosclerosis
Cardiac defibrillator
Amputation
Removal of orthopedic devices
Double joint replacement of the lower extremity
Other knee procedures
Pacemaker device replacement or revision
Combined anterior posterior spinal fusion
Complex non-cervical spinal fusion
AICD generator or lead
Total Count
12,653
64,807
23,617
28,964
22,906
19,852
82,606
104,418
119,282
5,769
Total Count
239,157
227,387
215,562
168,243
152,902
121,665
120,370
119,282
104,418
98,276
91,852
91,463
86,778
82,606
80,962
71,813
64,807
62,679
57,093
55,116
54,294
48,290
46,628
39,464
37,641
36,369
36,013
35,842
35,809
28,964
28,143
23,674
23,617
22,906
20,220
19,852
19,163
18,044
16,726
14,061
12,653
5,769
5,515
5,206
4,455
3,990
3,070
1,588
% Still in active care at
end of period
47%
41%
36%
36%
36%
33%
31%
30%
29%
28%
Lessons Learned From the Data
Analytics
• Payment variation
– Medical vs surgical DRGs
– Payment variation is due to post-acute care
and readmissions
• Episode length selection
– Depends on the diagnosis
• Hospital portion of the discount
• Quantifying the impact/effect of exclusions
Effective Hospital Discount
Total Payment
3% Discount
Hospital payment
Effective hospital
discount
$7,643,138
$229,294
$3,794,889
6.04%
Episode Length Risk
Full Episode
31-90 Day Episode Period
Discounts and Episode Length
Joint
Replacement
3% of 30 days
2% of 90 days
Difference
Total Discount
$209,103
$152,863
$56,241
Chest Pain
Total Discount
3% of 30 days
$13,087
2% of 90 days
$12,606
Difference
$481
Additional Lessons Learned
•
•
•
•
Data may not support intuition
Understand what data matters
Don’t over-analyze (until you have to)
Have a multi-disciplinary team together first
– Physician leadership is a key advantage
– Clinical interpretation of the data facilitates
decision-making
• Real program savings come from changing
utilization and care patterns both within and
outside the facility
Leveraging the Experience
• Analytics/metrics can be applied to:
– Commercial contracts
– Other innovative payment arrangements
• New payment arrangements are an
opportunity to cover costs for lost volume
(e.g. readmissions)
• If you are not part of the process, you will be
caught downstream of the savings
• Beware of the halo effect
Unanswered Questions
•
•
•
•
Who will succeed?
What will drive success?
How will success stories be shared?
How reproducible is success?
Contact Information
Gloria Kupferman
Vice President, National Information Products
DataGen, a HANYS Solutions Company
[email protected]
518-431-7968
www.datagen.info
Kelly Price
Director, DataGen Group
DataGen, a HANYS Solutions Company
[email protected]
518-431-7629
www.datagen.info
Where are the average dollars. . .
Episode Category
Complex non-cervical spinal fusion
Combined anterior posterior spinal fusion
Cardiac valve
Amputation
Hip & femur procedures except major joint
Coronary artery bypass graft
Cardiac defibrillator
Major cardiovascular procedure
Spinal fusion (non-cervical)
Double joint replacement of the lower extremity
Simple pneumonia and respiratory infections
Major joint replacement of the lower extremity
Chronic obstructive pulmonary disease, bronchitis, asthma
Congestive heart failure
Sepsis
Cardiac arrhythmia
Esophagitis, gastroenteritis and other digestive disorders
Urinary tract infection
Stroke
Renal failure
Gastrointestinal hemorrhage
Percutaneous coronary intervention
Other respiratory
Medical non-infectious orthopedic
Nutritional and metabolic disorders
Cellulitis
Hip & femur procedures except major joint
Syncope & collapse
Acute myocardial infarction
Chest pain
Major bowel procedure
Red blood cell disorders
Gastrointestinal obstruction
Transient ischemia
Pacemaker
Other vascular surgery
Medical peripheral vascular disorders
Diabetes
Spinal fusion (non-cervical)
Coronary artery bypass graft
Back & neck except spinal fusion
Major cardiovascular procedure
Lower extremity and humerus procedure exept hip, foot, femur
Cardiac valve
Cervical spinal fusion
Fractures of the femur and hip or pelvis
Revision of the hip or knee
Major joint replacement of the upper extremity
Atherosclerosis
Cardiac defibrillator
Amputation
Removal of orthopedic devices
Double joint replacement of the lower extremity
Other knee procedures
Pacemaker device replacement or revision
Combined anterior posterior spinal fusion
Complex non-cervical spinal fusion
AICD generator or lead
Total Count
3,070
3,990
22,906
12,653
64,807
28,964
14,061
23,674
35,809
5,515
Episode Category
Chest pain
Transient ischemia
Syncope & collapse
Esophagitis, gastroenteritis and other digestive disorders
Atherosclerosis
Cardiac arrhythmia
Gastrointestinal obstruction
Back & neck except spinal fusion
Chronic obstructive pulmonary disease, bronchitis, asthma
Gastrointestinal hemorrhage
Average 90
Day Total
$69,428
$66,866
$59,892
$48,445
$46,549
$45,276
$44,364
$38,983
$38,673
$38,389
Total Count
55,116
39,464
62,679
120,370
16,726
121,665
46,628
28,143
215,562
91,852
Total Count
239,157
227,387
215,562
168,243
152,902
121,665
120,370
119,282
104,418
98,276
91,852
91,463
86,778
82,606
80,962
71,813
64,807
62,679
57,093
55,116
54,294
48,290
46,628
39,464
37,641
36,369
36,013
35,842
35,809
28,964
28,143
23,674
23,617
22,906
20,220
19,852
19,163
18,044
16,726
14,061
12,653
5,769
5,515
5,206
4,455
3,990
3,070
1,588
Average 90
Day Total
$13,580
$16,043
$17,211
$17,408
$17,573
$18,062
$18,191
$18,738
$19,383
$20,437