Geisinger began its acute care episodic bundling of services with coronary artery bypass grafts, but has since begun to expand the concept into areas such as spine, coronary stents, cataracts, and pregnancy. And while much of the attention has gone to the all-inclusive single fee side of the arrangement, Ronald A. Paulus, MD, MBA, executive vice president of clinical operations and chief innovation officer at Geisinger, says the care process design is just as important.
"If you don't break the care process down and do fundamental reengineering, then you are shifting the financial paradigm, but you are not really shifting how Mr. or Mrs. Jones is taken care of," Paulus said. For CABG, multidisciplinary teams combed the evidence to select 42 discrete care process steps that were then embedded into the electronic medical record to "hardwire" them, Paulus said, so that they happen "100% of the time for every patient." Putting the process into the EMR is "the difference between a high-level guideline and an actionable care process step."
With the bundled care process, Geisinger's already low rate of inpatient mortality improved another 80% and the number of patients with complications improved by 13%, Paulus said. Besides the obvious benefits to care, total inpatient profit per patient was $1,946 to the hospital, while the health plan paid out 4.8% less per patient, and paid out 28% to 36% less to Geisinger than to other providers for CABG, said Jean A. Haynes, RN, MBA, president and CEO of Geisinger Health Plan.
"This is a win-win all the way," Haynes said. "The patient has better results. The financial performance for the provider is improved and on the payer side it is less."
Gundersen Lutheran, a physician-led, integrated system, has also begun to redesign care process around episodes of care, including breast care and bariatrics, said Sigurd B. Gundersen III, MD, medical vice president for Gundersen Lutheran Health System. The key has been to build around a multi-disciplinary care team approach, which in the case of breast care meant 19 different hospital teams, from radiation oncology to social services.
"This team approach is really critical to success," said Gundersen. "The question that often comes up is how you do this if you are not a system. I think you can. It is a little more work but any physician who practices is interested in improving the quality of care for their patients. If you do this right and show the results, people flock to this."
Building an ACO
While those health systems in an employed, integrated model have advantages when it comes to forming systems of care, even competitors can join under the structures of an accountable care organization, as Omaha's The Nebraska Medical Center, a 624-bed academic medical center, and Methodist Health System, a three-hospital community not-for-profit, did earlier this year.
"We had a shared vision that we wanted to look at improving the quality and outcomes for patients while also reducing the cost," said Kenneth W. Klaasmeyer, president of Methodist Health Partners and vice president of Methodist Health System. "The community in Omaha is really tired of health systems not working together. The community recognized and really thought this was very positive that two health systems would sit down and talk about how healthcare should be delivered."
In structure, both hospitals created a for-profit limited liability corporation called the Accountable Care Alliance, with each system choosing a board of six directors—five physicians plus the respective chief financial officers. Committees created so far include the executive committee, medical management, and credentialing. Physicians are asked to voluntarily join the PHO, and when they do they will agree to transparent quality measures that they will be accountable for, says Marcel Devetten, MD, chief quality officer for The Nebraska Medical Center.
"It needs to be exactly clear to all physicians what the ACO wants to accomplish. It needs to be crystal clear what outcomes measures physicians are going to be accountable for," he says. So far the group is starting to map out different processes, and reconciling different measures and definitions for outcomes, Devetten said. Even at this stage the exercise has forced each system to look at processes in a new way.
"If you talk about redesigning processes you actually assume that some of our present processes are designed," Devetten said. "As we all know they were not. They sort of evolved. It is interesting to do nothing but map out the flow of existing processes."