Download - Payment for Healthcare
Payment for Healthcare
Alignment with Safety, Appropriateness, and Quality
Accountable Payment Model SubgroupBree Collaborative Meeting
May 29, 2013
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Members of the SubgroupStaffed by Rachel Quinn and Kathryn Bergh
Providers1. Bob Mecklenburg, Virginia Mason, Chair2. Joe Gifford, Providence3. Tom Hutchinson, WSMA/WSMGMA4. Gary McLaughlin, Overlake
Purchasers1. Kerry Schaefer, King County2. Jay Tihinen, Costco
Health Plans1. Bob Herr, Regence2. Rich Maturi, Premera
Quality Organizations1. Susie Dade, Puget Sound Health Alliance2. Julie Sylvester, Qualis
Others: five orthopedists, including chair of State Association, a health plan orthopedist designee, and three orthopedist reviewers chosen by WSMA
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Overview of ProcessThe Accountable Payment Model Subgroup was
formed by the Potentially Avoidable Readmissions Workgroup
Task: develop warranty and bundled payment model Focus: total knee and total hip replacement surgeryGoals for today’s presentation:
1. Review sources used to develop draft warranty2. Receive feedback on current draft 3. Secure approval to submit draft for public comment4. Provide update on a standards for appropriateness, a
bundled payment model, and measures of quality
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Four Deliverables
Standards for appropriatene
ssSurgical bundleWarranty Measurements
of quality
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1. A Warranty for TKR and THR
Aligning payment with safety
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Current StatePayment Misaligned with Safety
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WarrantyAligning Payment with Safety
“…accepting responsibility for defects or liability for repairs over a specified period”
- Oxford English Reference Dictionary
“no payment for readmissions related to complications attributable to surgery”
- Accountable Payment Model Subgroup
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Warranty for TKR and THRFour Sources Guided Design
CMS data set for TKR and THR1. Technical Expert Panel (TEP) defined complications, frequency, timing, and codes
a. 12 member group included providers, patients, health plans, and consultantsb. Supported by 10 member Yale Core Team with technical expertise in measuresc. Supported by 6 member Working Group of 6 orthopedic content experts
2. Dartmouth’s High Value Healthcare Collaborative has adopted TEP definitions a. 19 medical centers across US plus Department of Defenseb. Population base of 70-100M patientsc. Grant from Center for Medicare and Medicaid Innovation
Data sets from Medicare FFS and Premera Bundle payment pilots in California and Wisconsin CMS bundled payment initiative
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General Content of Warranty
Complications included in warranty:1. Represent significant complications attributable
to TKR/THR procedures
2. Are identifiable in administrative claims data
3. Are fair to hospitals and physicians
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Specific Content of Warranty
Adults with TKR and THR surgery Periods of accountability are complication-specific
7 daysa. Acute myocardial infarction (heart attack)b. Pneumoniac. Sepsis (serious infection that has spread to bloodstream)
30 daysd. Deathe. Surgical site bleedingf. Wound infection
90 daysg. Mechanical complications related to surgical procedureh. Periprosthetic joint infection (infected implanted joint)
10 year warranty on disruption of the integrity of the joint prosthesis itself- attributable to provider
Hospital/provider group performing original surgery is accountable for payment for care of complications treated in another facility
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Next StepsAPM subgroup will meet tomorrow (May 30, 2013) to
finalize warranty based on Bree editsWe propose posting draft warranty on the Bree website
for public comment the first two weeks of June We propose asking partners to announce this public
comment period – HCA provider listserv, WSHA, WSMA, KC Med Society, and other orthopedic or interested groups
We will bring revised warranty to the July meeting for adoption
Today’s action step for Bree Collaborative: approve posting the draft warranty for public comment
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2. Standards for appropriateness
Avoiding unnecessary surgery
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Standards for appropriateness: Disability and Fitness for Surgery
1. Disability: reduced function and pain due to osteoarthritis despite conservative therapy
Document disability on standard scale Document osteoarthritis on standard scale Document explicit conservative therapy for at least 3 months Document failure of conservative therapy on standard scale
Evidence appraisal is complete
Standards for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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2. Fitness for surgery: physical preparation and patient engagement
Document adherence to safety standards regarding weight control, diabetes control, smoking
Document patient engagement: shared decision-making Specify care partner that assists patient throughout Document standard preoperative evaluation for surgery
Virginia Mason is appraising evidence for these items
Standards for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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3. Surgical BundleTransparent components of quality
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Surgical Bundle: Surgical Repair and Return to Function1. Surgical repair
Credentialing and standards for a surgical team Standards for optimal anesthesia Standard process for avoiding infection Standard process for avoiding bleeding Standards for avoiding thrombosis and embolism (blood clot in lung) Standards for maintaining optimal blood sugar Standards for selection of the surgical implant
Standards for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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2. Return to function Standard process for post-op care in the hospital Standardized hospital discharge process from
WSHA/Alliance/Qualis tool kit Standard process for arranging home health services Standard process for scheduling follow up appointments Standard process for measurement of functional
outcomes
Evidence appraisal is not complete for above elements
Standards for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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Intent is to bring completed clinical bundle to July meeting
Are health plans willing and able to administer warranty and bundles? If so, what is the timeline?
Standards for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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Progress with Deliverables
Direction from the PAR Workgroup
Progress of the APM Workgroup
Recommend episodes of focus Completed – Selected total hip and knee replacement surgeries.
Recommend warranty definition Completed – Presented at today’s meeting.
Recommend bundle In progress – Evidence appraisal of draft content is underway.
Recommend payment process• Prospective vs. retrospective• Unbundling guidelines
Not started
Recommend implementation timeline
Completed – Recommend implementation by 1/1/2014.
Define quality outcome measures
In progress – See next slides.
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4. Measurement of QualityThe guide to purchasing
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Group has discussed 5 broad categories of measures:1.Patient satisfaction2.Evidence-based care3.Functional improvement (Pre- and post-operation) 4. Avoiding readmissions5.Others, such as time to return to function
WarrantyStandards for appropriatene
ssSurgical bundle
Measurement of quality
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Quality measures currently under consideration:1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey as indicator of patient care experience
2. HOOS/KOOS and/or PROMIS-10 as indicator of improved function
Any recommendations for other indicators to consider?
Standard for appropriatene
ssSurgical bundleWarranty Measurement
of quality
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SafetyAppropriatenessQualityAffordabilityAccountability