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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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GABRIELLE WHITE , RN . CASC 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
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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
Our objectives 3
Create change in payment model
Improve care
Align providers
Provide value
Volume Demonstrate success
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
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$
Facility
Professional Warranty
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
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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
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bundle
team
episode
Manage risk
Outcomes payers
Claims
monitor
Team
Team selection ¡ Clinical
¡ Administration ¡ Support services
Roles
Communication
Meetings Reporting
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Team
Hospital/facility
Coordinator / project lead – connect the dots
Physicians
surgeon
anesthesia
Internist Nursing
Administration
Contracting
Revenue cycle
Benefits Registration
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Team
Professional Coordinator – liason with hospital MD office lead
Revenue cycle contracting benefits patient coordinator
Anesthesia Internist Other
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Team
Patient
Communicate
what
why
how
when
Educate
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Episode 13
Procedure ¡ Predictable
¡ High volume
¡ Known cost
¡ Known outcomes
Included Excluded
Time line
Warranty
Manage risk 14
Patient selection
Safe surgery
Health status
¡ BMI <38
¡ ASA 1-2, 1-3 ¡ Medical history
Manage risk
Providers
Volume
Quality
Outcomes
Cost
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Warranty 16
¡ Length
¡ Inclusions
¡ Exclusions
¡ Manage risk
¡ Provider data ¡ Self insured
¡ Re insurance
¡ Manage timeline
Outcomes
Quality benchmarks Volume
ALOS
SSI
DVT/PE rate
Re admission Claims
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Manage cost
Reduce waste Do what is necessary/best practice
Consider outcomes & risks
Know cost data per provider
Standardize
Work with vendors Share savings
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Payers
Commercial Employers
Private pay
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Payers
What do they want? Payer roadblocks
Payer concerns
How will they benefit?
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Hospital Surgeon
Anesthesia Other professional
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MD
Hospital Payer
Claims
Align all providers Pricing
Data
Who will manage claims?
Who will manage payments?
Process Contract between providers
Risk pool?
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Claims 24
Pre procedure
Post procedure/episode
One claim / multiple providers
One check / multiple providers
Coordination Payer concerns
Communication
Bundled alert!
surgeon
facility
Other professional
providers
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Communication
Patients Providers
Episode start > end
Outliers
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Care redesign 27
Align providers Claims management
Share risk
Standardize care
¡ Navigators
¡ Pre admission screening ¡ Infection prevention
¡ Transfusion rates
¡ Vendors
Provider contracting
Facility Surgeon
Surgeon assistant
Anesthesiologist
Other
¡ Hospitalist ¡ Radiologist
¡ Pathologist
¡ Cardiologist
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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
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Early Road blocks
Communication Payers
Providers
Knowing costs
Knowing data/outcomes
Process change Risk sharing
Price setting
Claims management
Warranty
Risks
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Monitoring success
Monthly reports
¡ Revenue cycle
¡ Performance improvement ¡ Peer review
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Getting started 32
¡ True & trusted leaders
¡ Payers ¡ Procedure
¡ Length of episode
¡ Warranty
Inclusion
exclusion ¡ Providers involved
¡ Data
¡ Rates
¡ Claims management
¡ Outcomes
Getting started
Cash global
Commercial global or bundled arrangement
Employer global or bundled arrangement
Consider a pilot
Start small
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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
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THANK YOU!
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