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

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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