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Physicians and Hospitals
Odd couple or match made in heaven
Mark I Froimson, MD, MBA
Former, President, Euclid Hospital
Cleveland Clinic
Now, Executive Vice President, Chief Clinical Officer
Trinity Health
Medical Updates
March 9, 2015
1
1
COI Disclosure (in last 5 years)
Consultant
MCS
DePuy Synthes
CITI
Speaker
Care Fusion
Research Support
Stryker
Leadership/Board Positions
MAOA Board member, AAHKS 3rd VP, AAOS, AF
Editorial Boards/Reviewer
JOA, AJO, JBJS
2
Cleveland Clinic: A Physician Group Practice
Led Academic Medical Center/Health System
Largely Integrated Model of Care
• 44,000 employee caregivers
• 5.1 million total visits
• 50 states and 132 countries patient
coverage
• 160,600 hospital admissions
• 3,000+ employed physicians and
scientists, plus private practice
• 8 community hospitals, 16 family
health centers
• Florida, Nevada, Toronto, Abu Dhabi
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3
Trinity Health: A National, Multihospital
Catholic Health System with mixed Medical
Staffing Model
• 89,000 employee colleagues
• 86 Hospitals, >100 continuing care
orgs
• 27 Regional Health Systems
• 21 states,
• 3,500+ employed physicians
• 25,000 affiliated physicians
• 30M patients in service areas
• 500,00 hospital admissions per year
4
4
Philosophy of accomplishment
"It's amazing how much you can
accomplish when you don't care who
gets the credit.“
Harry S. Truman
(leave your ego at the door)
Trust
Speak the Truth
Show Respect
Communicate Relentlessly
Physician Integration: Engaging Doctors in the
Health Care Revolution---HBR
Thomas Lee, MD, Toby Cosgrove, MD
• Shared Purpose
• Restore nobility of the calling
• Self Interest
• Financial Incentives
• Lifestyle
• Earning Respect
• Reputational significance, competitive streak
• Embracing Tradition
• Stewardship of profession
The Burning Platform? The call to action?
Is US healthcare a bad deal?
Does this motivate physicians?
8
Is it quality that is lacking in the industry
or is it reliability?
Gloria’s Email
….is John’s rehab physician. He
also needs a medical
doctor. Who would you
recommend?
….I think it’s time. I need a new
knee. Can you do it or who
would you recommend?
Desired Attributes of Health Care
Excellent
Safe
Expert
Reliable
Trustworthy
Reproducible
Predictable
Cleveland Clinic Tag Line
“Every Life Deserves World Class Care”
(Implied standard to aspire to)
March 3, 2015 l 11
The Quality/Reliability Problem: Adverse event
rate is high compared to other industries
The A- surgeon phenomenon
Do you ever choose your pilot when you fly?
Why not? Is it because you know that they
have standardized processes for safety?
“Big Med” Atul Gawande
Why Can’t Healthcare standardize like the
Cheesecake Factory?
March 3, 2015 l 14
Are there better comparisons?
Mode of Transportation
Mode of Transportation
Comparatively reliable 98.5%
What degree of sameness and reliability do we
expect from a new car?
Why is this missing in health care?
We don’t all want the same car.
But when we choose a product we expect to get
what was promised
Reliability in Industry :
How do we move this in healthcare?
Selection
Training
Credentialing
Culture
System and team based thinking
Clarity of offering—standard
product
Standardization Process---4 E’s
Engage
Explain why the interventions
are important
Evaluate
Educate
Regularly assess for
performance measures and
unintended consequences
Share the evidence supporting
the interventions
Execute
Design an intervention
“toolkit” targeted at
barriers, standardization,
independent checks,
reminders, and
learning from mistakes
Pronovost PJ, et al. BMJ. 2008;337:963-5
.
From Autonomy as the defining trait to system
based thinking…The Elements of Change
•
•
•
•
•
•
Culture is everything, need to get buy in
Acceptance of current state and past success
Burning Platform—What is the imperative?
Shared Vision of Ideal state
Direction and Path forward
Can we think in new ways about how we deliver
care?
Why Health Care Is Stuck And How to Fix It
Drive Value for Patients
by Michael E. Porter and Thomas H. Lee, HBR
Bundled
Payments
We All know what needs to be done:
Keys to Driving Value in Health Care
 Care Coordination
 Best Practices
 Care Paths
 Reducing disutility
Improving Quality
 Streamline
Processes
 Eliminate
Waste/Redundancy
 Shift Care to Lower
Intensity Venue
Reducing Cost
How do we get physicians involved in
improving quality and reducing cost?
Sebastian Thun, on getting things done:
---Need an extrinsically set goal
The big game, big test phenomenon
Driverless Car
DARPA
Google Glass
Innovation Challenge
What is our external challenge?
The Industry is Changing: Navigating the
Affordable Care Act
l 23
Our Catalyst for Change: 2010 PPACA
Perhaps the most important Affordable Care Act
mandate: the creation of the
Center for Medicare and Medicaid Innovation
to explore new payment models for integrating care
ACO Model for Primary care
Bundled Payments for Care Improvement
Episode of Care Model gives physicians a
vehicle to restore sense of professionalism
• Fulfill a promise to patients—better care
• Opportunity for Financial gain and ease of
practice
• Metrics of success
• Competitive performance
• Sustainability of the profession
Health Care Reform: Approaches to Care
Two paradigms in health care reform
Medical Home/ACO
Health Status
1
Managing baseline health
needs (population health):
preventive care, chronic
care, health maintenance
Episode Management/Bundles
2
Managing episodes
of care: hospitalizations,
surgical interventions (joint
replacement)
Baseline=40%
Episode= 60%
Cleveland Clinic Complete Care:
Creating Value Through Episode Management
Premise:
When change in health status demands intervention, managing
the entire episode is preferable to fragmented care delivery
Tactic:
Care redesign focusing on improved care coordination and
patient and provider engagement yields better care at lower
cost
Strategic Imperative:
Providers who master this approach will have a competitive
advantage in the marketplace
Four Models of Bundled Payment
offered by CMMI/BPCI
41%
36%
Only
Complete
Episode
16%
7%
I
II
III
Model
1
2 and retrospectively
Modeladjusts
3
Use
current
FFS paymentModel
system
Acute Inpatient
And Prof
Acute Inpatient
Prof, Post-acute
Post-Acute only
IV
Model 4 Payment
Prospective
Acute Inpatient
And Prof.
EH one of only 13 to go live “at risk” October 1, 2013
>4000 providers are in the pipeline with proposals
Source: Advisory Board
Bundled Payment for an Episode: TJR
• Composite product, includes all care for the episode
• Triggered by a Hospitalization/Surgical event
• Coordinated to optimize resource utilization and outcome
$$$ one price for episode
Care coordinator
$
$
Prim
Care
Ortho
O
O
Jan
Feb
Mar
Courtesy C. Donovan
Apr
$
PreAdmit
May
TJR
Rehab/
Snf/hc Readmit?
O
H
O
Jun
Jul
Aug
7 days pre
Prim
Care
H
Sep
O
Oct
30-90 days post
Nov
Dec
CMMI/BPCI Basics
• A CMS contracting entity (initiator) chooses one or more
Episodes from among 48 (covering 172 DRGs)
• 10/13 CC/Euclid Hospital---DRG 469/470 Total Joint
• CMS provides historic hospital specific MSPB* for the
episode which sets the base price
• Entity evaluates ability to beat that target price
• Entity sets duration for the episode that defines discount
• 3% discount for 30 day or 2% for 90 day
• Price is locked in for 3 years
• Physician billing and revenue cycle does not change
under the program; CMS distributes BPCI gains
retrospectively each quarter
*Medicare Spend per Beneficiary
Getting the work done: Define the episode
Example of Joint Replacement
Engage the team
Steps
Specifics for TJR
1. Medical Condition:
Define the entity to be
treated
Advanced, symptomatic, recalcitrant arthritis hip/knee
DRG 469,470
2. Health Outcomes of
interest
Pain free, functional joint by the end of the episode—
interval outcomes that need to be addressed!
3. Define population: who
are we treating?
• Patients with the medical condition who are indicated
and optimized for this treatment rather than none or
alternate
• Risk Stratification, Exclusion of certain populations
4. Define intervention
Primary TKA, THA
5. Define initiating event
and timeline
-7,TJR,+30days, 90, 180
6. Define resources needed
to produce outcomes:
people, places, processes
• Includes all professional, lab and technical components
• Includes all preop and post op care, inpatient and
outpatient care
Euclid Hospital Episode
BPCI summary
Bundle
MS DRGs 469 & 470
Primarily Total hip/knee replacements*
Episode Duration
7 days prior and 30 days post
Episode Initiator
Target Price
Euclid Hospital (EH)
$18,948 (MS-DRG 470)
$28,673 (MS-DRG 469)
3% off 2009-2011 EH MSPB for DRG
Patient Population
Medicare fee-for-service patients
Duration of contract
3 years (10/1/13 – 9/30/16)
All costs of care above CMS contracted
price including readmissions within 30
days
Savings beyond 3% cost reduction for
episode
Risk
Reward
*These MS-DRGs also include ankle replacements and some hip
fractures
Key Provisions:
Waivers and Gainsharing
Waivers
• 3-day hospital stay for PAC payment
• Home bound status for Home Care
• Pre-hospital home safety check
Gainsharing
•
•
•
•
Opportunity to share risk and reward among providers
Physicians can receive up to 50% bonus over FFS rates
Based on performance measures and rules
Within a CIN or other collaborative arrangement
The Business Case: Value is Created by Better
Episode Management through Care Redesign
Traditional fragmented delivery
Cost
(revenue)
Portion of savings to payer
Value creation
Available
margin for
provider
New Model of Care
Time
The Patient Perspective: Viewing Care as a
Complete Episode is What Patients Want
Provider Centered:
Bundled Payment
Patient Centered:
Complete Care
35
Episode-Based Complete Care Philosophy
Our Promise to Patients: We will deliver all the care needed to
get you through entire episode of care
Care Path
utilization:
Following best
practices
Care
Coordination:
Working
seamlessly
together
Connected
Care:
Providing care
in appropriate
venue
Patient Commitment: You must be engaged in the process,
bring resources, get educated and work to modify your risk
36
Care Redesign Opportunities:
Complete Care Principles
• Patients do not want unneeded interventions
• Patients want to go home as soon as it is safe
• It is our job to:
• Arrange and optimize the entire episode
up front
• Educate them on the options for care
and enable early return to home
• Make them feel safe
• Eliminate unnecessary interventions
Complete Care Principles
• Leadership is essential – Physician is the team leader
• Builds culture, restores joy and professionalism
• But it takes a team approach, must engage team
• Eliminate unneeded steps or resources
• Patients don’t want unnecessary care
• Time in an institution should be minimized
• Resist impulse to do something as the default
• More is not always better: be thoughtful
• Engaged/educated patients are our greatest assets
• The care we offer should integrate into their lives
What’s old is new again…but with better tools to
implement
Care Redesign Opportunities Across the Care Continuum
The Cleveland Clinic Complete Care Framework
Developed by a collaborative team to direct the work (100’s)
Patient Presents
with Medical Condition
Indications for proposed
intervention
Pre Operative
Patient Optimization and
Risk Assessment
Shared Decision Making
Care Path Implementation
Decision support
Best Practice-EBM
Discharge planning: Rapid
Recovery protocol
Connected Care Team
Care Coordination
Patient Engagement
Family and Community
Support and safe home
environment
Resource optimization
Risk and Complete Care Management:
Principles agreed to by physician leaders
• Modify the risk factors that the patient brings
• Factors that impact anesthetic/mortality risk
• Factors that impact wound healing
• Factors that impact rehabilitation potential
• Inform patient about the impact that risk factors
confer on outcomes
• Engage patient in managing and optimizing
medical and social determinants of success
Two Separate Processes:
Indication vs. Optimization
Is this patient indicated for surgery?
•
•
•
Sufficient symptoms interfering with ADL, work or recreation,
QOL
Inability of alternative treatment to resolve symptoms
Objective evidence of joint disease amenable to surgical
correction
Is this patient optimized for surgery?
Should it be scheduled or delayed based on:
• Psychologically and Medically fit for surgery
• Adequate support and home environment
TJA Preoperative Planning and
Assessment: invest up front in process
Change the work flow for surgical scheduling
from
Indication----Scheduling---Optimization
to
Indication----Optimization----Scheduling
Allows optimal patient, family and system
preparation to ensure shared decision making
and smooth care through episode
Preoperative Checklist: Managing Risk for
Readmission and increased LOS after TJR
Role of Predictive Analytics
1. Diabetes: Hgb A1c if >7.9 delay and refer
2. Smoker: if YES then refer to smoking cessation
3. BMI: if >40---refer for counseling, metabolic
consult
4. Anemia: if Hgb <12 in females and <13 in males,
delay and refer for wu or blood management*
5. Staph colonization: if in HC facility or HC worker or
hx of MRSA, screen and decolonize
6. Narcotic dependence, manage upfront
7. Anticoagulation history or need perioperatively
8. Lack of supportive home environment
Care Path Protocols:
Eliminating Unnecessary interventions
Physicians must drive standardization
No more daily lab draws
No X-ray in PACU for knees
No IV PCA
No Ice Man or CPM
No Femoral Block
No bipolar sealer
No bulky dressing, drains
No routine Foley Catheter
Use TXA. Local blocks
Rapid Recovery Protocol
2012: Home-Going rates by Surgeon
Unwarranted Variation
% of Patients Discharged to HOME / HOME CARE:
DRG 470, Medicare Patients, All Hips and Knees (n=2,281)
75%
70%
65%
Rapid recovery patients, who go through education
US News Ortho Top 20
benchmark (51.1%)
60%
55%
50%
45%
Includes surgeons with >=10 total cases
Dark Blue = Employed surgeon; Light Blue = Community
40%
35%
Traditional unmanaged
patients
30%
25%
20%
15%
10%
5%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Surgeon
Patient/Family Engagement and Home
environment: An underutilized opportunity
Standardize the approach across practices
•Go into the home
pre-op and make
modifications
•Preoperative
education and
counseling is key
•Rapid Recovery
Identify a reliable care giver / support
Must agree on a discharge date and
venue of post acute care
All patients coming from home should plan
to go home
Decide up front on transportation
Identify impediments to home DC
Stairs/bedroom/bathroom on same
floor
Distance from hospital
Building Business Intelligence Tools
to Clearly Define and Track Performance
Clinical Outcomes
Patient Safety
Process
measures
Physical therapy day of surgery
Decrease in pain medications needed
Compliance with Care Path
Core measures
Patient optimization prior to surgery
Outcomes
measures
PRO, HOOS/KOOS
Return to work/sports
Range of motion
PT test, Pain free
Pt safety indicators, SSI, Readmissions,
Re-operations, Post operative falls,
Post-op nausea/vomiting
Transfusion
Process
measures
Outcomes
measures
Patient Experience
Efficiency
Patient and family education
Engaged and activated patients
Family/Support person involvement
Quality shared decision making
Appt. when wanted
Feel prepared for discharge
Joint class
Resource utilization
Cost of care
Utilization Review: avoiding unnecessary
tests, Reduced LOS, Discharge disposition
Rapid Recovery program
HCAHPs
Return/second surgery
Total cost of care
Contributions to cost (acute, post acute venue,
complications, readmissions)
48
Quality and experience are improved
Q1 2013
Q1 2014
SNF
56%
22%
DC Home
39%
77%
CAUTI rates
5.2%
0
Transfusion rate
15%
2%
Infection rate
.75%
0.0%
Readmission
5%
1.6%
IP LOS
3.4
2.8
49
Transparent Sharing of Performance Measures:
Cost and Quality Metrics by Physician and
versus the target price
Revenue Reconciliation per case with CMS
51
Q4 2013, Q1 2014 CMS
Revenue Reconciliation
DRG
470
469
Benchmark
Price
$19,319
-
Target
Price
$18,739
-
Episode
Cases
Target
Amount
Medicare
Spend
165 $3,091,935 $2,905,605
0
-
Gain Due
to Euclid
$186,285
-
Note: Total Cost per Case = 17,610 Margin = $1129 per Medicare TJR
Care Redesign reduced FFS revenue by $281,985
• In FFS model, CMS would have all savings, in
BPCI model. CMS gets $95,700 savings
• Euclid is receiving a $186,285 gain share
BPCI is an excellent model for providers to both
deliver value to payers and retain value created
Pre BPCI FFS episode payments
Cost
(revenue)
CMS limited to 3%
$95,000
Value creation
Episode of care payment
in BPCI
Better Quality/lower cost
CCF retains
value created
$186,000
Available for
GainSharing
Gain Sharing: Guidelines
• Develop Risk Pool
• As part of Quality Alliance
• Clinically Integrated Network
• Process Metrics
• Participation in development, reporting
• Compliance with Complete Care protocols
• explain deviation when appropriate--learning
• Outcome of the cohort
• specialty specific
• entire cohort
Offering a New Product to the Market:
Benefiting Patients, Engaging Physicians
Cleveland Clinic
Complete Care
Episodes
Clinically based
End to end redesign
Lead with Quality
Differentiated Clinical
Capabilities
Care Path
Care Coordination
Connected Care
Clear Metrics
Analytic capabilities
Value Proposition: Complete Care Management
Patient Centered
Better patient decisions, less anxiety
Least disutility of care, complications, pain
Improved outcomes
Physician Friendly
More efficient care delivery
Gain Sharing opportunities
Better patient satisfaction, experience = referrals
System resources deployed to free surgeon
Health System Friendly
Efficient use of resources
Financially remunerative
Attracts Physicians and Patients
Next Steps: Additional CMS 48 Standard Bundles
Acute myocardial
infarction
AICD generator or
lead
Hip & femur
procedures except
major joint
Chest pain
Lower extremity and
Combined anterior
humerus procedure
posterior spinal fusion exept hip, foot, femur
Other vascular surgery Stroke
Pacemaker
Pacemaker device
replacement or
revision
Percutaneous
coronary intervention
Syncope & collapse
Complex non-cervical
Amputation
spinal fusion
Major bowel
Transient ischemia
Congestive heart
Major cardiovascular
Atherosclerosis
failure
procedure
Urinary tract infection
Major joint
replacement of the
Red blood cell
Back & neck except
COPD,
lower extremity
disorders
spinal fusion
bronchitis/asthma
Major joint upper
Removal of orthopedic
CABG
Diabetes
extremity
devices
Double joint
replacement of the
Medical non-infectious
Cardiac arrhythmia
lower extremity
orthopedic
Renal failure
Esophagitis,
gastroenteritis and
Medical peripheral
Revision of the hip or
other digestive
Cardiac defibrillator
disorders
vascular disorders
knee
Fractures femur and Nutritional and
Cardiac valve
hip/pelvis
metabolic disorders
Sepsis
Gastrointestinal
Other knee procedures Simple pneumonia and
Cellulitis
hemorrhage
respiratory infections
Spinal fusion (nonCervical spinal fusion GI obstruction
Other respiratory
cervical)
Lessons Learned Based on Early Experience
• Physicians embrace key leadership role in episode
management—drivers of change
• Financial opportunities to gain share
• Embrace change and opportunity: competitive advantage
• Patients Benefit
Care Redesign
Patient
Engagement
Quality
Improvement
Cost Reduction
Thank You
Regional Hospitals
March 3, 2015 l 59