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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
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
5
$
Facility
ProfessionalWarranty
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
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
bundle
team
episode
Manage
risk
Outcomespayers
Claims
monitor
Team
  Team selection
¡  Clinical
¡  Administration
¡  Support services
  Roles
  Communication
  Meetings
  Reporting
9
Team
Hospital/facility
Coordinator / project lead – connect the dots
  Physicians
surgeon
anesthesia
Internist
  Nursing
  Administration
Contracting
Revenue cycle
Benefits
Registration
10
Team
Professional
Coordinator – liason with hospital
  MD office lead
Revenue cycle
contracting
benefits
patient coordinator
  Anesthesia
  Internist
  Other
11
Team
Patient
Communicate
what
why
how
when
Educate
12
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
15
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
17
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
Payers
  Commercial
  Employers
  Private pay
19
Payers
  What do they want?
  Payer roadblocks
  Payer concerns
  How will they benefit?
20
21
Hospital Surgeon
Anesthesia Other
professional
22
MD
HospitalPayer
Claims
  Align all providers
  Pricing
  Data
  Who will manage claims?
  Who will manage payments?
  Process
  Contract between providers
  Risk pool?
23
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
25
Communication
  Patients
  Providers
  Episode start > end
  Outliers
26
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
28
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
Early Road blocks
  Communication
  Payers
  Providers
  Knowing costs
  Knowing data/outcomes
  Process change
  Risk sharing
  Price setting
  Claims management
  Warranty
  Risks
30
Monitoring success
  Monthly reports
¡  Revenue cycle
¡  Performance improvement
¡  Peer review
31
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
33
  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
-
THANK YOU!
35

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