what is value in regional anesthesia?

@EMARIANOMD@EMARIANOMD

What is Value in Regional What is Value in Regional Anesthesia?Anesthesia?

What is Value in Regional What is Value in Regional Anesthesia?Anesthesia?

Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.

Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare

Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem

Edward R. Mariano, M.D., Edward R. Mariano, M.D., M.A.S.M.A.S.

Associate Professor of AnesthesiologyAssociate Professor of AnesthesiologyStanford University School of MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative Chief, Anesthesiology and Perioperative CareCare

Veterans Affairs Palo Alto Health Care Veterans Affairs Palo Alto Health Care SystemSystem

What is Value in Regional Anesthesia? What is Value in Regional Anesthesia?

Financial DisclosuresFinancial DisclosuresFinancial DisclosuresFinancial Disclosures Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun –

Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.

Halyard (formerly I-Flow), B Braun – Halyard (formerly I-Flow), B Braun – Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.


Learning ObjectivesLearning ObjectivesLearning ObjectivesLearning Objectives

Discuss the value-based purchasing Discuss the value-based purchasing program and its components; program and its components;

Identify aspects of the HCAHPS survey Identify aspects of the HCAHPS survey that directly and indirectly relate to that directly and indirectly relate to inpatient pain management; inpatient pain management;

Apply strategies to demonstrate value Apply strategies to demonstrate value and justify costs of supporting an and justify costs of supporting an acute pain serviceacute pain service

Discuss the value-based purchasing Discuss the value-based purchasing program and its components; program and its components;

Identify aspects of the HCAHPS survey Identify aspects of the HCAHPS survey that directly and indirectly relate to that directly and indirectly relate to inpatient pain management; inpatient pain management;

Apply strategies to demonstrate value Apply strategies to demonstrate value and justify costs of supporting an and justify costs of supporting an acute pain serviceacute pain service


OverviewOverviewOverviewOverview

““Value-based” purchasingValue-based” purchasing Measuring the patient experienceMeasuring the patient experience Demonstrating value and justifying Demonstrating value and justifying

costcost

““Value-based” purchasingValue-based” purchasing Measuring the patient experienceMeasuring the patient experience Demonstrating value and justifying Demonstrating value and justifying

costcost



Value-based purchasingValue-based purchasing Measuring the patient experienceMeasuring the patient experience Demonstrating value and justifying Demonstrating value and justifying

costcost


costcost


History: “P4R” to “P4P”History: “P4R” to “P4P”History: “P4R” to “P4P”History: “P4R” to “P4P” 2003 Medicare Modernization Act: 2003 Medicare Modernization Act:

Inpatient Prospective Payment System Inpatient Prospective Payment System hospitals voluntarily reported hospitals voluntarily reported performance metrics to avoid reductions performance metrics to avoid reductions in paymentin payment

2005 Deficit Reduction Act: included pay-2005 Deficit Reduction Act: included pay-for-for-reportingreporting (P4R) but mandated (P4R) but mandated development of development of value-basedvalue-based purchasingpurchasing or pay-for-or pay-for-performanceperformance (P4P) to start in (P4P) to start in FY09FY09

2003 Medicare Modernization Act: 2003 Medicare Modernization Act: Inpatient Prospective Payment System Inpatient Prospective Payment System hospitals voluntarily reported hospitals voluntarily reported performance metrics to avoid reductions performance metrics to avoid reductions in paymentin payment

2005 Deficit Reduction Act: included pay-2005 Deficit Reduction Act: included pay-for-for-reportingreporting (P4R) but mandated (P4R) but mandated development of development of value-basedvalue-based purchasingpurchasing or pay-for-or pay-for-performanceperformance (P4P) to start in (P4P) to start in FY09FY09


Institute of Medicine 2012Institute of Medicine 2012Institute of Medicine 2012Institute of Medicine 2012

http://www.iom.edu/http://www.iom.edu/bestcarebestcare

Investment Required!


Authorized by the Affordable Care Act Authorized by the Affordable Care Act but has been around longerbut has been around longer

““Pays for care that Pays for care that rewards better value, rewards better value, patient outcomes, and innovations,patient outcomes, and innovations, instead of just volume of services”instead of just volume of services”

Funded by a 1.25% Funded by a 1.25% withholdwithhold from from participating hospitals’ Diagnosis-participating hospitals’ Diagnosis-Related Group (DRG) payments Related Group (DRG) payments (2% by (2% by 2017)2017)

Authorized by the Affordable Care Act Authorized by the Affordable Care Act but has been around longerbut has been around longer

““Pays for care that Pays for care that rewards better value, rewards better value, patient outcomes, and innovations,patient outcomes, and innovations, instead of just volume of services”instead of just volume of services”

Funded by a 1.25% Funded by a 1.25% withholdwithhold from from participating hospitals’ Diagnosis-participating hospitals’ Diagnosis-Related Group (DRG) payments Related Group (DRG) payments (2% by (2% by 2017)2017)

Value-Based Purchasing Value-Based Purchasing (VBP)(VBP)

Value-Based Purchasing Value-Based Purchasing (VBP)(VBP)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/downloads/Instruments/hospital-value-based-purchasing/downloads/HospVBP_ODF_072711.pdfHospVBP_ODF_072711.pdf




costcost


costcost


FY2014 Value-Based FY2014 Value-Based PurchasingPurchasing

FY2014 Value-Based FY2014 Value-Based PurchasingPurchasing

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/NPCSlides071112.pdfhospital-value-based-purchasing/Downloads/NPCSlides071112.pdf

*NEW*

*NEW*


Assessing Patient Assessing Patient ExperienceExperience

Assessing Patient Assessing Patient ExperienceExperience

Patients are surveyed using the Patients are surveyed using the Hospital Consumer Assessment of Hospital Consumer Assessment of Healthcare Providers and Systems Healthcare Providers and Systems (HCAHPS)(HCAHPS)11

32 questions32 questions Publicly reportedPublicly reported 4 times a year 4 times a year22

HCAHPS is administered to a random HCAHPS is administered to a random sample of adult inpatients between 48 sample of adult inpatients between 48 hours and six weeks after dischargehours and six weeks after discharge

Patients are surveyed using the Patients are surveyed using the Hospital Consumer Assessment of Hospital Consumer Assessment of Healthcare Providers and Systems Healthcare Providers and Systems (HCAHPS)(HCAHPS)11

32 questions32 questions Publicly reportedPublicly reported 4 times a year 4 times a year22

HCAHPS is administered to a random HCAHPS is administered to a random sample of adult inpatients between 48 sample of adult inpatients between 48 hours and six weeks after dischargehours and six weeks after discharge1. http://www.hcahpsonline.org1. http://www.hcahpsonline.org

2. 2. http://www.hospitalcompare.hhs.gohttp://www.hospitalcompare.hhs.govv


Satisfaction Isn’t EverythingSatisfaction Isn’t EverythingSatisfaction Isn’t EverythingSatisfaction Isn’t Everything

but we are scored on it!but we are scored on it!but we are scored on it!but we are scored on it!


HCAHPS QuestionsHCAHPS QuestionsHCAHPS QuestionsHCAHPS Questions DirectlyDirectly relate to pain:relate to pain:

– During this hospital stay, During this hospital stay, how oftenhow often was was your pain well controlled?your pain well controlled?

– During the hospital stay, During the hospital stay, how oftenhow often did did the hospital staff do everything they the hospital staff do everything they could to help you with your pain?could to help you with your pain?

DirectlyDirectly relate to pain:relate to pain:– During this hospital stay, During this hospital stay, how oftenhow often was was

your pain well controlled?your pain well controlled?– During the hospital stay, During the hospital stay, how oftenhow often did did

the hospital staff do everything they the hospital staff do everything they could to help you with your pain?could to help you with your pain?


HCAHPS QuestionsHCAHPS QuestionsHCAHPS QuestionsHCAHPS Questions IndirectlyIndirectly relate to pain:relate to pain:

– Before giving you any new medications, Before giving you any new medications, how how oftenoften did the hospital staff tell you what the did the hospital staff tell you what the medicine was for?medicine was for?

– ……did the hospital staff describe possible side did the hospital staff describe possible side effects in a way that you could understand?effects in a way that you could understand?

– Using a number from 0-10, what number Using a number from 0-10, what number would you rate this hospital during your stay?would you rate this hospital during your stay?

– Would you recommend this hospital to your Would you recommend this hospital to your friends and family?friends and family?

IndirectlyIndirectly relate to pain:relate to pain:– Before giving you any new medications, Before giving you any new medications, how how

oftenoften did the hospital staff tell you what the did the hospital staff tell you what the medicine was for?medicine was for?

– ……did the hospital staff describe possible side did the hospital staff describe possible side effects in a way that you could understand?effects in a way that you could understand?

– Using a number from 0-10, what number Using a number from 0-10, what number would you rate this hospital during your stay?would you rate this hospital during your stay?

– Would you recommend this hospital to your Would you recommend this hospital to your friends and family?friends and family?


Scoring HospitalsScoring HospitalsScoring HospitalsScoring Hospitals

“Incentive” = How Much Withholding Hospitals Get Back




costcost


costcost


Develop Patient Care Develop Patient Care PathwaysPathways

Develop Patient Care Develop Patient Care PathwaysPathways

Hebl JR, et al. JBJS 2005;87 Suppl Hebl JR, et al. JBJS 2005;87 Suppl 2:632:63


TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)TKA Protocol (VA Palo Alto)

PreopPreop 1.1. Adductor canal catheterAdductor canal catheter

2.2. Oral gabapentin if opioid-Oral gabapentin if opioid-dependentdependent

OROR Spinal anesthesia, LIA, IV Spinal anesthesia, LIA, IV acetaminophenacetaminophen

PostoPostopp

1.1. Continuous perineural infusion Continuous perineural infusion (0.2% ropivacaine 6 ml/h basal)(0.2% ropivacaine 6 ml/h basal)

2.2. Oral NSAID and acetaminophen Oral NSAID and acetaminophen ATCATC

3.3. Oral opioid ATC and PRNOral opioid ATC and PRN

4.4. IV opioid PRN but no IV PCAIV opioid PRN but no IV PCAMariano, et al. Adv Anesthesia 2013;31:119Mariano, et al. Adv Anesthesia 2013;31:119


Patients in the adductor Patients in the adductor canal group walked canal group walked 3737 (0-90) meters vs. (0-90) meters vs. 66 (0- (0-51) meters in the 51) meters in the femoral catheter group femoral catheter group ((p=0.003p=0.003). ).

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of stay hospital length of stay were similar. were similar.

Patients in the adductor Patients in the adductor canal group walked canal group walked 3737 (0-90) meters vs. (0-90) meters vs. 66 (0- (0-51) meters in the 51) meters in the femoral catheter group femoral catheter group ((p=0.003p=0.003). ).

Pain scores, opioid Pain scores, opioid consumption, and consumption, and hospital length of stay hospital length of stay were similar. were similar.

Promote Early Promote Early RehabilitationRehabilitationPromote Early Promote Early RehabilitationRehabilitation

Mudumbai & Mariano, et al. CORR Mudumbai & Mariano, et al. CORR 2014;472:13772014;472:1377


Mariano, Walters, Kim, Kain. A&A Mariano, Walters, Kim, Kain. A&A 2015;120:11632015;120:1163Walters, Mariano, Clark. Pain Med, in press.Walters, Mariano, Clark. Pain Med, in press.


Avoid “Never” EventsAvoid “Never” EventsAvoid “Never” EventsAvoid “Never” Events

Federal Register May 3, Federal Register May 3, 20072007


Avoid “Never” EventsAvoid “Never” EventsAvoid “Never” EventsAvoid “Never” Events

Federal Register May 3, Federal Register May 3, 20072007

Avoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) EventsAvoid “Never” (Get Paid) Events


Anesth Clinics 2014;32:853


Cost Savings Benefit the Cost Savings Benefit the HospitalHospital

Cost Savings Benefit the Cost Savings Benefit the HospitalHospital

Increasing Phase I PACU bypassIncreasing Phase I PACU bypass Changing PACU nurse:patient ratiosChanging PACU nurse:patient ratios Decreasing unplanned hospital Decreasing unplanned hospital

admissionsadmissions Decreasing ER visitsDecreasing ER visits Shortening length of stay (e.g., joint Shortening length of stay (e.g., joint

replacement)replacement)

Increasing Phase I PACU bypassIncreasing Phase I PACU bypass Changing PACU nurse:patient ratiosChanging PACU nurse:patient ratios Decreasing unplanned hospital Decreasing unplanned hospital

admissionsadmissions Decreasing ER visitsDecreasing ER visits Shortening length of stay (e.g., joint Shortening length of stay (e.g., joint

replacement)replacement)

……Not You!Not You!……Not You!Not You!


Deliver a Consistent ProductDeliver a Consistent ProductDeliver a Consistent ProductDeliver a Consistent Product

• Do you have 24/7 in-Do you have 24/7 in-house coverage for OB house coverage for OB anesthesia?anesthesia?

• If so, how do you pay for If so, how do you pay for it?it?

• Many hospitals provide a Many hospitals provide a stipendstipend


SummarySummarySummarySummary We discussed the value-based We discussed the value-based

purchasing program and its purchasing program and its components components

We identified aspects of the HCAHPS We identified aspects of the HCAHPS survey that directly and indirectly survey that directly and indirectly relate to inpatient pain management; relate to inpatient pain management;

We discussed potential strategies We discussed potential strategies demonstrate value and justify costs demonstrate value and justify costs of supporting an acute pain serviceof supporting an acute pain service

We discussed the value-based We discussed the value-based purchasing program and its purchasing program and its components components

We identified aspects of the HCAHPS We identified aspects of the HCAHPS survey that directly and indirectly survey that directly and indirectly relate to inpatient pain management; relate to inpatient pain management;

We discussed potential strategies We discussed potential strategies demonstrate value and justify costs demonstrate value and justify costs of supporting an acute pain serviceof supporting an acute pain service


Questions?Questions?Questions?Questions?

“The sooner patients can be removed from the depressing influence of general hospital life the more rapid their convalescence.”

- Dr. Charles Mayo, Lancet 1916

what is value in regional anesthesia?

Healthcare

costdemonstrating value

regional anesthesia

valuebased purchasingdiscuss

valuebased purchasing

value andapply strategies

patient experiencemeasuring

medicare modernization

deficit reduction act