key: cord-0955211-oxngl3nc
authors: Halder, Gabriela E.; Cardwell, Jessica; Gao, Hanhai; Gardiner, Haley; Nutt, Stephanie; White, Amanda; Young, Amy; Rogers, Rebecca G.
title: Creating a Bundled Care Payment Model for Treatment of Pelvic Floor Disorders: Introducing Value into Urogynecology
date: 2020-06-09
journal: Am J Obstet Gynecol
DOI: 10.1016/j.ajog.2020.06.005
sha: 5f5bb81b6881340e1666425b7f892d85f966e315
doc_id: 955211
cord_uid: oxngl3nc

Abstract Ineffective healthcare delivery and expenditures associated with traditional fee for service in-person models have turned attention towards alternative payment models as a means of enhancing healthcare quality in the United States. Bundled Care Payment Models are a form of alternate payment models that provide a single reimbursement for all services rendered for an episode of care and have been developed extensively in primary care settings with limited literature in urogynecology. We describe the process used to create a Bundled Care Payment Model for women seeking care in a pelvic floor disorders subspecialty clinic in partnership with our safety net insurer. The process included estimation of prior average spend, the design of an integrated practice unit, creation of pelvic floor pathways, approximation of utilization rates, and estimation of reimbursement and expenses.

Ineffective healthcare delivery and expenditures associated with traditional fee for service 40 in-person models have turned attention towards alternative payment models as a means of 41 enhancing healthcare quality in the United States. Bundled Care Payment Models are a form of 42 alternate payment models that provide a single reimbursement for all services rendered for an 43 episode of care and have been developed extensively in primary care settings with limited 44 literature in urogynecology. We describe the process used to create a Bundled Care Payment 45

Model for women seeking care in a pelvic floor disorders subspecialty clinic in partnership with 46 our safety net insurer. The process included estimation of prior average spend, the design of an 47 integrated practice unit, creation of pelvic floor pathways, approximation of utilization rates, and 48 bundled payments as an APM 3 . Bundled Care Payment Models (BCPM) provide a single 72 reimbursement for all services rendered to a patient for an episode of care rather than separate 73 payments for each individual service. An episode of care is defined as the total care a patient 74 receives for a particular condition including both in person and telehealth clinic visits, diagnostic 75 testing, and operative care. For example, in a BCPM, a clinic would receive one lump sum for 76 all of the care surrounding the management of prolapse including the initial clinic visit, 77 urodynamic testing, surgery, and post-operative visits. Bundled care time limits are implemented 78 based on the estimated episode of care. For example, BCPM for acute conditions may be 79 restricted to 90 days postoperative, but chronic conditions may be longer such as a year. Quality 80 is emphasized through BCPM because if the cost for the care rendered for a particular episode is 81 less than the bundled payment amount, providers keep the difference. However, if the cost 82 exceeds the payment, the providers absorb the loss. Cost of care is reduced by following evidence-based guidelines that result in overall improved patient outcomes. Healthier patients 84 have fewer visits to the emergency room, readmissions, and use of ancillary testing, and 85 prescription medications. Patient reported outcomes are obtained to ensure improvement in 86 medical conditions and satisfaction with care. 87

The impact of BCPM on healthcare cost and quality is mixed and still being investigated. (Table 1) . Uninsured patients receive access to primary and subspecialty medical care In an IPU, care is multi-disciplinary, collocated, team-based, patient-centered, and 124 provides the full scope of care for a condition. Patients are able to receive supportive services 125 (such as social work and psychiatry), conservative therapies (such as nutrition and pelvic floor 126 physical therapy), and, if needed, surgical planning for their condition in the same clinical setting 9 . The PFD IPU is located in a new clinical space allowing all multidisciplinary services to 128 be co-located 10 . Healthcare coordination across services and providers in most traditional FFS 129 clinics is poor and not incentivized; often patients are left coordinating their own care across 130 multiple institutions. The IPU addresses this by providing care as a team. A key concept in the 131 creation of the IPU is the "graduation" of patients back to their primary care provider once their 132 subspecialty care is complete, which ensures that access to urogynecologic care is maintained. The process of creating a BCPM can be found in Figure 2 . The first step in creating our 150 BCPM was estimation of past spend. The yearly average spend by our safety net insurer for 151 women with PFD was estimated using historical claims data from a FFS environment. These 152 rates were inclusive of surgical, professional and ancillary services and facility fees. 153

Time driven activity-based costing (TDABC) was used to estimate the amount of time 154

and level of provider needed for each pathway was estimated using 13 ( Table 2) . Care pathways 155

were deconstructed to units of activity. For example, units of activity in the prolapse pathway 156 included physical therapy, pessary fitting, urodynamics, and surgery. Figure 1 shows cost 157 estimation for our SUI pathway. The projected utilization rates for each unit of activity along 158 each pathway were estimated using a combination of prevalence data for that particular disorder, 159 trends in claims data, information from local clinics, and expert opinion. fee for that surgery and did not include hospital charges. 166

Using the above methodology, population-based resource utilizations were estimated, 167 these estimates may not be applicable to other populations. The estimated clinic utilization was 168 three visits per patient in one year. Surgical rates and use of pelvic floor physical therapy were 169 estimated at 10% and 60%, respectively. Forty percent of patients were estimated to require 170 diagnostic procedures (such as cystoscopy and urodynamics) and durable medical equipment 171 (such as pessaries and catheters). Physician staffing was estimated to be 1. implementation of a BCPM were unavailable because patients were previously seen in private 192 clinics outside of the UTHA system and were not administered measures that would have 193 allowed that comparison. We implemented our BCPM in an IPU setting, but the IPU is not 194 necessarily a feature of this payment model. Using performance measures that focus on improved patient reported outcomes and decreased health care costs can change the priority of 196 doctors to observe best practice if they want to join a practice that has adopted these models." 197

Returning women back to their clinic home for continued surveillance is a key feature of our 198 model and requires the development of expertise in our FQHCs for managing stable patients. For 199 women that have conditions that are too complicated, an additional year of care is being re-200 negotiated. 201

In conclusion, BCPM are a promising method of delivering value-based care in 202 urogynecology. As our health care system rapidly adjusts to the sweeping changes brought about 203 by the coronavirus epidemic, BCPM offers a systematic way to introduce streamlined, effective 204 care. Although the care model presented here was created in an IPU setting, it can be 205 implemented in any gynecologic setting without co-located services and care pathways. Step 1 Select a medical condition • Specify a medical condition and patient population affected • Identify criteria that define the beginning and end of a care cycle • Determine possible complications (urinary retention, wound infections, return to the operating room) • Specify resources used for the specific medical condition and possible complications Step 2

Define the care delivery chain • Map the principal activities involved in the care of the medical condition and their delivery location (office, operating room, telehealth)

Step 3

Develop process maps of each activity in patient care delivery • Process maps detail patients' movement along the care delivery pathway including the use of capacity-supplying resources (personnel, facilities, and equipment) and consumable supplies (Foleys, syringes, and medications) Step 4

Obtain time estimates for each process • Estimate the amount of time each provider or resource spends within each step of the process map Step 5

Estimate the cost of supplying patient care resources • Estimate the direct cost of each resource within each step of the process map including physician salaries and support resources (office furnishing, employee development, stocking consumable supplies)

Step 6

Estimate the capacity of each resource and calculate the capacity cost rate • The clinical availability for each employee is determined by calculating the number of days per year and number of hours per day and employee is available for clinical work (excludes breaks and administrative time) • The same is performed for equipment, considering the use capacity of the equipment itself (amount of UDS test the machine can perform), and the capacity of use by the clinic (amount of UDS tests the clinic orders) • Resource capacity cost rate: resources total cost (step 5)/practical capacity (step 6) Step 7

Calculate the total cost of patient care • Multiply the capacity cost rate for each resource used in each patient process by the amount of time spent with the resource (step 4) Reference: Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev. 2011 Sep; 89(9):46-52, 54, 56-61 passim. 

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