Some employers are starting to contract instantly with supplier organizations for healthcare. To accomplice with self-insured employers, Nashville-based Vanderbilt College Medical Heart has developed value-based care bundled fee applications for a number of the commonest and dear well being circumstances, resembling maternity, orthopedics and cardiology. Healthcare Innovation just lately spoke with Brittany Cunningham, D.N.P., M.S.N., R.N., who has led efforts to launch and broaden VUMC’s direct-to-employer industrial bundles with the purpose of providing predictable pricing and concierge-level expertise for sufferers, whereas saving cash for employers and sufferers.
HCI: Your title is vp for the Episodes of Care Workplace underneath Inhabitants Well being at Vanderbilt. May discuss a little bit bit about your nursing background and the way you got here to guide this program?
Cunningham: After I suppose again, I by no means imagined that I might be doing one thing like this. I did not even comprehend it existed after I bought into nursing 20-something years in the past. I’ve been at Vanderbilt for happening 22 years. I used to be the standard and affected person security advisor for the Coronary heart Institute. As CMS began placing extra give attention to value-based care and lowering price and growing high quality, I used to be able to essentially give attention to that work. I used to be answerable for reportable outcomes, lowering readmissions, after which CMS began piloting applications like bundled fee care initiatives. Vanderbilt needed to pilot that program and that was a part of my accountability. That is how I bought my first style of bundled funds. Then Vanderbilt mentioned we wanted to begin focusing extra on this. I began this workplace in 2015. At one time we have been doing over 40 populations with Medicare. The State of Tennessee additionally does Medicaid episodes of care. Then we began specializing in the direct-to-employer industrial populations in 2018 after which actually ramped it up in 2019 and went stay in 2020. We took our experiences from the federal government facet and translated it to the industrial facet and developed it ourselves. HCI: Is there a distinction between the way you do bundles in direct to employer vs. in Medicaid or Medicare? Cunningham: There are some similarities, however I feel the largest distinction is the best way that we’ve structured our definitions. We go on to our clinicians and say, don’t be concerned concerning the payer. We’re very clinically centered. We allow them to resolve the best way they need to present the take care of the affected person, and what they really feel is greatest evidence-based care. Then we create a fee mannequin round it. With Medicare and Medicaid, they’re coming to us because the payer and they’re making an attempt to chop prices out of the system, after which we’ve to supply the medical care beneath it. So we’re flipping it round. We are saying what’s the greatest medical care doable — after which we put a fee mannequin round it.
HCI: Is without doubt one of the objectives eliminating medical variation? Do clinicians need to agree on what the very best evidence-based factor to do is after which everybody within the division goes to observe that?
Cunningham: Sure, completely. Everybody has to comply with this pathway. A extremely nice instance is C sections. For our maternity bundle, we’ve a mix of vaginal and C-section charges. We now have one worth for that collectively, so it is a locked-in utilization fee. So should you go over that utilization, you are not going to receives a commission extra. We’re not going to pay for C-sections simply to have a C-section, which is the fee-for-service mannequin. We’re actually taking that incentive away from the suppliers to do one thing simply to do it.
HCI: However does that result in attention-grabbing conversations between the clinicians as they attempt to come to an settlement?
Cunningham: That’s a very attention-grabbing query. We’re speaking to a brand new supplier group concerning the C-section dialog and they’re actually enthusiastic about it as a result of they really feel they get penalized by some payers for his or her C-section fee. We are literally incentivizing them to do the suitable factor, which is that if you do not have to do a C-section we’ll incentivize you to not try this C-section, the place there are payers which are simply ratcheting down that purpose of C-sections and never incentivizing them to do the suitable factor.
HCI: Is one facet of this improved communication with the sufferers — maybe extra digital communications in order that so that they’re clear what to anticipate to occur by way of the episode?
Cunningham: In creating the bundle, we actually centered on three completely different elements. We centered on the medical care. We centered on the monetary portion, which is that fee mannequin and it is a locked-in worth, so there’s predictability for the employer, and transparency for that.
The opposite key half is that we waive the affected person portion, so we’re giving price financial savings to the affected person additionally. After which we give attention to the expertise. How will we make this a greater expertise for the affected person? We did not need to simply put lipstick on a pig. We needed to really make it a greater expertise. We added affected person navigators, who stroll sufferers by way of the bundle. For maternity a bundle could be so long as 12 months lengthy, so understanding what’s included and what’s not included is vital. The navigator is there for any query that is not clinical-related. The affected person can name for instructions, for getting an appointment scheduled. For any query, they’ve that one level of contact. The navigator will ship data to the affected person at key factors in the course of the bundle and in the course of the journey. So as a substitute of giving a guide of schooling and a bulk of data, they will ship little e-mails or little items of data at key factors. We broke it down so we did not overwhelm the affected person and it actually helps the affected person perceive what to anticipate.
HCI: Have you ever gathered patient-reported consequence information on the again finish to check that to a management group of people that aren’t in a program like this?
Cunningham: We do acquire useful patient-reported outcomes for our ortho sufferers, however we’ve not carried out that comparability but of whether or not their patient-reported outcomes are completely different than for the non-bundle sufferers. I feel that is in our future. We do have survey information, which is affected person satisfaction information. Our web promoter rating is is extraordinarily excessive. It is within the eighties, and it has been for a few years now. We even have outcomes information like C-section charges. Our C-section charges are decrease than the non-bundle sufferers. One other attention-grabbing information level is that our NICU charges are decrease.
HCI: Are you able to gauge the employer satisfaction, both by way of continued participation or progress in this system?
Cunningham: We have had a couple of key employer for the reason that starting. We at the moment have 5 employers on contracts. These employers who’ve been with us for the reason that starting have added extra applications. One employer mentioned they needed to begin with maternity after which about six months later they mentioned they have been going so as to add extra applications. We simply talked to them just lately they usually’re occupied with including much more applications, so that they see the good thing about it they usually see that their members are appreciating the profit.
HCI: Do the employers you’re employed with need to be self-insured?
Cunningham: They do need to be self-insured. And the reason being as a result of the foundations round self-insured vs. absolutely insured. Totally insured is just not as versatile, however with self-insured, you’re basically writing your individual guidelines of your advantages, and you’ll be extra versatile with including value-based applications like this.
HCI: You’ve added fairly a couple of completely different bundles over time. Vanderbilt has developed bundles round maternity, listening to, backbone, orthopedics, weight reduction, urology, substance use dysfunction, and cardiology. Are there much more issues that could possibly be put right into a bundle?
Cunningham: We now have that dialog so much. What’s the restrict of what could be bundled? I feel there are extra that may be. For those who’re acquainted with bundle applications, everyone form of goes after the ortho stuff first. We figured that is what we’d do. However then we began speaking with certainly one of our employer companions they usually mentioned that maternity is what they wanted. Maternity was the place their excessive spending and variability was. That is what they wanted assist with, so we pivoted and we did maternity first, which was very useful as a result of that was 2019. And we began in 2020. That was when COVID hit, and we nonetheless did ortho proper after that. We had a lot quantity coming by way of with maternity and we discovered so much about how you can administer this and how you can change the definitions. We attempt to take heed to our employers and our companions and ask: The place are your ache factors and what do you want? We get a whole lot of suggestions. I simply heard just lately that they need a diabetes bundle. There are applications that we are able to create which are value-based care in order that it is serving to them with their spend, and making a greater expertise for the affected person.
HCI: At concerning the time Vanderbilt was beginning to do that work, have been there different well being programs across the nation additionally doing one thing related that you would mannequin your program after or have been you form of pioneering a few of this work?
Cunningham: 5 years in the past, I might say, there weren’t very many on the market. There have been a pair doing extra of the “facilities of excellence” mannequin, which is admittedly centered on procedures and never the excellent mannequin like we have been creating. After which there’s the Medicare mannequin. So these have been the 2 that we might have a look at, however not the best way that we needed to construction it, which is the extra complete expertise and the chance that we needed to tackle. I’ve talked to a whole lot of establishments throughout the nation and extra are attempting to get into this house and transfer within the route that we’ve moved, which is nice. I like that there are extra folks desirous to do it. And a few are keen to tackle the chance that we’ve taken on, however I might say that there is solely a handful.
