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Key measures in orthopedics
- 1. Key Measures and Analytics in Orthopedics Mary Ann Clark, MHA SVP Intralign
- 2. • Alignment of surgeons and hospitals, clinical and operational outcomes • Integration of tools and strategies in TJA to enhance transparency and accountability • Change Management - Strength and capability to affect lasting change for systems seeking lasting change Bending the cost curve Intralign’s innovative approach
- 3. Pre-OP Care: 3 - 30 Days (eg.) Acute Phase* Post-Acute: 30 - 180 Days (eg.) Payer, Consumer, Employer Perspective of Health Care Costs = Reimbursement Intraoperative Rest of Acute Phase 2% 35% 38% 25% = 100% * Acute Phase includes both facility and physician costs. Implant = 60% of OR Costs Total Episode Costs = $22,000 - $32,000
- 5. Variation in Implant Costs and Total Inpatient Costs is Significant
- 6. Addressing Drivers of OR Costs can Produce ‘Quick Wins’… Rectifying Operational and Clinical Inefficiencies Hospital Cost Drivers • Implant Cost • Cutting Accessories • Cement Accessories • PAT and SPD • Environmental Protection • Patient-Specific Cutting Blocks • Navigation • Device Complexity Process transformation and supply chain solutions add efficiencies. Highly qualified clinical staff increases throughput, reduces costs and increases quality.
- 7. The Role of the Sales Rep • Lack of price transparency and rep presence leads to unnecessary up-sell • Rep or multiple reps in OR slows room turnover • Clinical support provided by the rep is not free – charged through hefty SG&A implant cost Influencing the Cost of Orthopaedic Implants The result: Loss of control, reduced efficiency and higher supply costs.
- 8. Intralign’s Rep-less Assessment Identify where Hospital is on the “Rep-less Roadmap” related to: Reliance on the sales rep Surgeon alignment Staff capabilities Implant and supply management Vendor contract management Quantify the potential benefits (financial and operational) of adopting a Rep-less model Potential dollars saved per procedure Financial benefits resulting from standardized processes Objectives
- 9. Session Overview • Why Measure? • What to Measure? • Resources, Tools, Measure Alignment/harmonization • Measure development • A Framework for Performance Measurement in Orthopedics • Measure Development and Implementation • Managing Change and Improving Performance in the Orthopedic Service Line – Case Studies
- 10. Regulation Quality Outcomes Reimbursement Satisfaction Market Influences Consumerism Satisfaction Market Share Internal Operations Costs Revenue Cycle Efficiency Processes Mission Quality Outcomes Why do we need to measure? “If you can’t measure it, you can’t improve it.” – Peter Drucker External Internal
- 11. CMS Program # Measures in FY 2015 Measure Types Value-Based Purchasing 23 (# related to TJA = 15) Process, Outcomes, Patient Experience, Efficiency Readmission Reduction 5 (1 pertinent to TJA) All-cause TJA readmissions within 30 days Hospital Acquired Conditions (HAC) 3 (All pertinent to TJA) CLABSI, CAUTI, Patient Safety Composite Measure CMS - Monitoring and Managing Key TJA Cost, Quality, Operational and Patient Satisfaction Measures to Achieve Value Many more measures for quality reporting.
- 12. How does VBP impact hospital reimbursement? 25% 45% 30% 30% 20%2… 30% Outcomes (Mortality) Process Measures Patient Experience (HCAHPS) REIMBURSEMENT Process Measures (New) Efficiency (Medicare Spending) REIMBURSEMENT Outcomes Measures • i.e. Acute Myocardial Infarction Process Measures • i.e. Prophylactic antibiotics given 48 hrs. before surgery Patient Experience Measures • i.e. Communication with nurses Efficiency Measures • i.e. Medicare spending per beneficiary 2014 2015 Patient Experience (HCAHPS) Outcomes (Mortality) Outcomes Measures • i.e. Acute Myocardial Infarction Process Measures • i.e. Prophylactic antibiotics given 48 hrs. before surgery Patient Experience Measures • i.e. Communication with nurses Shifting focus on outcomes and efficiency measures
- 13. Clinical and Operational Improvement “It’s not a matter of whether orthopaedic surgeons want to have measures of accountability and improvement in defining their performance,” he said. “Orthopaedic surgeons are being rated today by a number of different stakeholders.” – Kevin Bozic, MD, MBA – Orthopedic Surgeon and Health Policy expert, UCSF “We’ve been doing performance measures in a way for many years, beginning with process measures on issues such as antibiotic administration…. The trend now, as propelled by CMS and other payers, is toward use of subjective patient- reported outcomes. They want to know how the interaction with the doctor or surgeon went and how the surgery went.” – David A. Halsey, MD.
- 14. Identifying Key Measures • Processes, utilization, and outcomes • Target audiences/Users? • Importance to measure and report • Ability to interpret and act on findings • Feasibility to measure • Identifiable and measurable denominators
- 15. Example Resources for Orthopedic Measures CMS/Commercial Payers – Quality – process of care reporting; Outcomes – complications, readmissions, mortality, hospital acquired conditions; patient satisfaction; volume thresholds Registries – AHRQ-FORCE Registry – clinical outcomes, PROs, costs; California Joint Replacement Registry Societies/Associations – AAOS (outcomes), HFMA (financial, revenue cycle) Research Groups – AHRQ, Robert Wood Johnson Foundation, NQF – outcomes, cost (payer perspective), quality Literature – Operating Room efficiency measures Other Hospitals – internal efficiency Create your own, tailored to your institution’s needs
- 16. A Framework for Key Measures in Orthopedics – Balance is Key • Procedure Volume • Avg. Age, Age Distribution, Sex Distribution, Ethnicity Distribution • Avg. Charlson Score • ASA Category Distribution • Payer Mix • DRG Mix • Surgeon Mix, Others Patient Demographics • Avg. Cost • Avg. Reimbursement • Avg. Net Revenue • Procedure Volume • Supplies, implantables Costs, Others Financial Impact • Composite Event Rate • Joint/Wound Infection Rate • DVT/PE Rate • Mechanical Complication Rate • ALOS • % Admitted to ICU • % Discharged to Home/Self Care • % with Spinal Anesthesia, Others Quality and Outcomes • Overall Efficiency Score • Contribution Margin per OR Hour • Avg. Case Duration • Avg. Case Duration Prediction Bias • Avg. Turnover Time, Others Operational Efficiency Patient Satisfaction
- 17. Importance of Key Measures in Orthopedics: Key Stakeholder Perspectives 4.67 4.93 4.87 4.47 4.71 3.07 4 4.6 4.4 4 3.27 3.53 4.73 4.53 4.93 3.873.85 2.46 2.38 3.08 0 1 2 3 4 5 6 Administrator Clinician Patient Payer Rating Key Stakeholder Perspective Quality and Outcomes Financial Operational Efficiency Patient Satisfaction Demographics/Stratification
- 18. Example Key Measure Specification Measure Name: #358 Patient-centered Surgical Risk Assessment and Communication Description: Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon Numerator: Documentation of empirical, personalized risk assessment based on the patient’s risk factors with a validated risk calculator using multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient and/or family Denominator: The total number of adult patients (age 18 and over) having had non-emergency surgery Exclusions: None Measure Type: Process Measure Steward: American College of Surgeons http://riskcalculator.facs.org/
- 19. Potential data needed for Key Measure Calculations UB-04 Scheduling OR-Anesthesia Log Operative Note/Implant Log Cost Accounting/ Supply Chain • Unique Patient Billing Identifier • Unique Patient Medical Identifier • Hospital Admission Date • Hospital Discharge Date • ICU Admission Date • ICU Discharge Date • MS-DRG • ICD-9 Diagnosis Codes 1 - XX • ICD-9 Procedure Codes 1 - XX • Admission Source • Discharge Destination • Payer • Total Charges • Total Reimbursement • Patient Responsibility • Revenue Center Code • Charge Code • HCPCS Code • OR / Room Identifier • Case Identifier • Block Allocation • Cancellation Status • Cancellation Date • Scheduled Case Start (Wheels In) • Scheduled Case End (Wheels Out) • Unique Patient Billing Identifier • Unique Patient Medical Identifier • OR Suite / Room Identifier • Primary Surgeon • Anesthesiologist • Number of RNs • Number of Surgical Technicians • Sales Representative • Surgical First Assist • Operative Date • Anesthesia Induction • Anesthesia Ready • Wheels In - Actual • Surgeon In • Surgical Incision • Surgical Close • Patient Wake • Surgeon Out • Wheels Out - Actual • Start Clean • End Clean • Admission to PACU • Tourniquet Time • ASA Score • Unique Patient Medical Identifier • Procedures Performed • Implants used • Cement Fixation • Antibiotic Cement • Bone Morphogenic Protein • Anesthesia Type • Estimated Blood Loss • Complications • Surgical Approach • Operative Site (right/left) • Infection Prophylaxis Protocol Followed • DVT Prophylaxis Protocol Followed • Patient Surgical Prep Protocols • Unique Patient Billing Identifier • Cost • Contract Status • Contract Initiation • Contract Renewal • Internal Identification Code • Manufacturer • Manufacturer Catalog Number • Vendor • Vendor Catalog Number • Description • Quantity
- 20. Potential Data Sources Orthopedic Key Measures Claims Data Warehouse Cost Accounting System Implant Logs Device Manufacturer Contracts ORIS/AIS Custom Data Collection?
- 21. Post-op discharge Surgeon’s Office Scheduling Pre-Reg PAT Pre-Op OR PACU Inpatient Discharge Post-acute care Process of Care Transformations to Improve Outcomes and Costs Risk assessment and pre-admission Scheduling and block time Surgical patient through-put Communication hand-offs Instrument flow
- 22. Assigned Responsibility Assigned Responsibility Assigned Responsibility Strategy Deployment Strategy Goals / Dashboard Key Measures Projects Patient Experience Provider Satisfaction Clinical Outcomes Readmission Rates Length of Stay OR Turnover % Cases Cancelled PACU Delays Net revenue Volume Growth Financial Operational SatisfactionClinical Vehicle for PI and Strategy Deployment Training Balanced Scorecard Leading Lagging Indicators
- 23. Summary • Consistent, substantiated data is a key factor in engaging physicians and staff to achieve success • Plan for the long term • Success doesn’t happen overnight • Build relationships with people who can help you • Many people are there to assist (both internal and external), but you may have to search for them • Communicate results regularly with front-line staff • They will be very engaged in the process • They can have a big impact on achieving positive outcomes • Don’t overlook small successes
- 24. For the presentation in full go to: http://www.intralign.com/library/ resources/