payment for healthcare alignment with safety, appropriateness, and quality accountable payment model...

Payment for Healthcare

Alignment with Safety, Appropriateness, and Quality

Accountable Payment Model SubgroupBree Collaborative Meeting

July 18, 2013

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Goals for Today’s Presentation

1. Summarize findings from the public comment period for the draft warranty on total knee and total hip replacement (TKR and THR) procedures

2. Adoption of the revised warranty by the Bree Collaborative

3. Provide update on standards for appropriateness, a bundled payment model, and measures of quality

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Four Deliverables

Standards for appropriateness

Surgical bundleWarrantyMeasurements

of quality

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1. A Warranty for TKR and THR

Aligning payment with safety

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Overview of Public Comment Process

APM subgroup developed an online survey

Posted survey announcement and link on the Bree Collaborative website

Local community partners and national groups promoted the survey through their networksComplete list in the posted summary document

Survey was open for 2 weeks (6/19-7/3)Modified on 6/20 to allow respondents to provide

only general feedback due to clinical/technical nature of many of the warranty definitions

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Profile of Respondents

62 people started the survey

46 people completed it

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Key Findings from Public Comments

Broad support for diagnostic codes (91%), procedure codes (96%), and age limits (84%)

Support for complications ranged from 35% (acute myocardial infarction) to 67% (surgical site bleeding)

57% agree with the warranty periods in the first 90 days

42% agree with the 10-year implant warranty

53% agree with the term that holds the hospital performing the TKR/THR surgery accountable for treatment received for complications at another hospital of outpatient facility

Note: Sample sizes for all of these percentages are included in the posted summary document

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Recurring Themes from

Public Comments

Warranty limits access to TKR/THR for patients that are at an increased risk of any of these complications

• “This will change the face of orthopaedics forever and limit access to those who need it the most ... the elderly, the poor, those who have medical comorbidities.”

Workgroup response:

• Patients that are at an increased risk of complications are not always appropriate candidates for surgery• Adhering to appropriateness criteria helps ensure that patients have a safe procedure and smooth

recovery

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Public Comments

Complications are unavoidable, so providers shouldn’t be punished for them

• “Including events that occur even in the best case of care creates unfair burdens on hospitals and physicians.”

Workgroup response:

• Baseline complication rates reflect current care practices – the benchmark should be zero

• We want to get to the point where it’s not dangerous to go to the hospital

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Public Comments

Complications often result from patient factors/behaviors that providers cannot control

• “[The warranty] makes a flawed assumption that all risks and complications are controlled on the provider side when patients make unhealthy choices in life which we can not mitigate.”

Workgroup response:

• Patient factors can be addressed through comprehensive pre-operative screening, patient education, identification of a care partner, and other components of the bundle

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Public Comments

Implant manufacturers should be responsible for design/manufacturing defects, not providers

• “I wonder about holding the hospitals responsible for defects in prostheses. Is there any way to get the manufacturers to accept responsibility for their devices?”

Workgroup response:

• Hospitals and providers should only purchase/use implants that have a low failure rate. Manufactures should also be held responsible. This provision is difficult to administer.

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Public Comments

Implementing the warranty is very difficult (e.g. attributing complications to the TKR/THR procedure)

• “It sounds like an administrative nightmare for hospitals, providers and whomever is providing oversight for the program.”

Workgroup response:

• The CMS Technical Expert Panel (TEP) defined code sets approved by orthopedic content experts, suggesting that they are feasible to administer

• Recognize the difficulty of administering a 10-year warranty for implant

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Changes Made in Response to Public

Comments•Death is only included as a complication in the warranty if it is attributable to any of the other complications in the warranty

Clarify when death is included in the warranty

•Including the code sets that the TEP used to define all of the complications in the warranty as an appendix

Clarify definitions for all

complications

•Instead of including a 10-year implant warranty, quality criteria for the implant will be added to the bundle

Remove the 10-year implant

warranty

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Other Efforts to Aid Implementation

•To account for price variability across hospitals, the subgroup recommends applying a fixed amount equal to the allowable amount for treating that complication using Medicare fee schedule•An alternative option is, to create two categories of amounts: a set amount for a readmission without surgery and twice that when surgery is needed

Researching appropriate

penalties for care received at a

second hospital

•Establishing third party groups that could help mediate disputes between health plans and providers; these groups could resolve such issues about whether treatment was for a condition attributable to the TKR/THR procedure

Researching options for

dispute resolution

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Content of Warranty Adults with TKR and THR surgery

Periods of accountability are complication-specific7 days

a. Acute myocardial infarction (heart attack)b. Pneumoniac. Sepsis (serious infection that has spread to bloodstream)

30 daysd. Deathe. Surgical site bleedingf. Wound infectiong. Pulmonary embolism

90 daysh. Mechanical complications related to surgical procedurei. Periprosthetic joint infection (infected implanted joint)

Hospital/provider group performing surgery should be accountable for payment for care of complications treated in another facility according to single transparent market standard based on CMS fee schedule

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Proposal to Adopt Draft Warranty

The APM subgroup proposes that the Bree Collaborative adopt the revised Total Knee and Total Hip Replacement (TKR and THR) Warranty.

Note: The APM subgroup is planning to wait until all four components of the TKR/THR bundle are completed before submitting a report to the Health Care Authority.

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Outreach & Communication Plan

In process

To educate community about the warranty and other components of bundle

Partner with stakeholders: WSHA, WSMA, employers such as Seattle Chamber of Commerce, other employer groups

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The following slides contain information on the other parts of the bundle; there’s no new substantive developments to report to the Bree

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2. Standards for appropriateness

Avoiding unnecessary surgery

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Evidence appraisal is complete for both sections of the standards for appropriateness:

1. Disability: reduced function and pain due to osteoarthritis despite conservative therapy

2. Fitness for surgery: physical preparation and patient engagement

No action needed from the Bree at this time

Standards for appropriatene

ss

Surgical bundle

WarrantyMeasurement of quality

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3. Surgical Bundle

Transparent components of quality

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Evidence appraisal for both parts of the bundle (Surgical Repair and Return to Function) is almost complete

Expect to present a draft bundle to the Bree Collaborative at the September meeting


Standards for appropriatene

ss

Surgical bundle


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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 almost done.

Recommend payment process• Prospective vs. retrospective• Unbundling guidelines

In progress – Have started to develop provisions related to accountability for complications.

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 Quality

The guide to purchasing

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Group has discussed 5 broad categories of measures:

1.Patient satisfaction

2.Evidence-based care

3.Functional improvement (Pre- and post-operation)

4. Avoiding readmissions

5.Others, such as time to return to function

WarrantyStandards for appropriatene

ss

Surgical bundle

Measurement of quality

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Progress made with several measures:

1. Endorse HOOS/KOOS as the preferred method for assessing disability, including pain

2. Agree NIH’s quality of life tool, PROMIS-10, is a promising tool

3. Agree HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is a good tool for measuring patient experience


Standard for appropriaten

ess

Surgical bundle


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