Some employers are starting to contract straight with supplier organizations for healthcare. To associate with self-insured employers, Nashville-based Vanderbilt College Medical Heart has developed value-based care bundled cost packages for a few of the commonest and expensive well being situations, corresponding to maternity, orthopedics and cardiology. Healthcare Innovation not too long ago 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 aim of providing predictable pricing and concierge-level expertise for sufferers, whereas saving cash for employers and sufferers. 

HCI: Your title is vice chairman for the Episodes of Care Workplace beneath  Inhabitants Well being at Vanderbilt. May speak a bit of 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’d be doing one thing like this. I did not even comprehend it existed after I acquired 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 value and rising high quality, I used to be able to essentially give attention to that work. I used to be liable for reportable outcomes, lowering readmissions, after which CMS began piloting packages like bundled cost care initiatives. Vanderbilt needed to pilot that program and that was a part of my duty. That is how I acquired 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 had 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 reside 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 believe the most important distinction is the best way that we now have structured our definitions. We go on to our clinicians and say, don’t be concerned concerning the payer. We’re very clinically targeted. We allow them to resolve the best way they wish to present the take care of the affected person, and what they really feel is greatest evidence-based care. Then we create a cost mannequin round it. With Medicare and Medicaid, they’re coming to us because the payer and they’re attempting to chop prices out of the system, after which we now have to offer the medical care beneath it. So we’re flipping it round. We are saying what’s the greatest medical care attainable — after which we put a cost mannequin round it.

HCI: Is likely one of the objectives eliminating medical variation? Do clinicians need to agree on what one of the best evidence-based factor to do is after which everybody within the division goes to observe that?

Cunningham: Sure, completely. Everybody has to conform to this pathway. A very nice instance is C sections. For our maternity bundle, we now have a mix of vaginal and C-section charges. We now have one value for that collectively, so it is a locked-in utilization fee. So if you happen to 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 extremely 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 fitting 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 might be simply ratcheting down that aim of C-sections and never incentivizing them to do the fitting factor.

HCI: Is one side of this improved communication with the sufferers — maybe extra digital communications in order that in order that they’re clear what to anticipate to occur via the episode?

Cunningham: In creating the bundle, we actually targeted on three totally different elements. We targeted on the medical care. We targeted on the monetary portion, which is that cost mannequin and it is a locked-in value, 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 value financial savings to the affected person additionally. After which we give attention to the expertise. How can we make this a greater expertise for the affected person? We did not wish to simply put lipstick on a pig. We needed to really make it a greater expertise. We added affected person navigators, who stroll sufferers via the bundle. For maternity a bundle might be so long as 12 months lengthy, so understanding what’s included and what’s not included is essential. 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 info to the affected person at key factors in the course of the bundle and in the course of the journey. So as an alternative of giving a guide of schooling and a bulk of data, they’re going to 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 knowledge on the again finish to match that to a management group of people that aren’t in a program like this?

Cunningham: We do acquire purposeful patient-reported outcomes for our ortho sufferers, however we now have not performed that comparability but of whether or not their patient-reported outcomes are totally different than for the non-bundle sufferers. I believe that is in our future. We do have survey knowledge, which is affected person satisfaction knowledge. Our internet promoter rating is is extraordinarily excessive. It is within the eighties, and it has been for a few years now. We even have outcomes knowledge like C-section charges. Our C-section charges are decrease than the non-bundle sufferers. One other attention-grabbing knowledge level is that our NICU charges are decrease.

HCI: Are you able to gauge the employer satisfaction, both via continued participation or development 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 packages. One employer mentioned they needed to begin with maternity after which about six months later they mentioned they had been going so as to add extra packages. We simply talked to them not too long ago they usually’re interested by including much more packages, in order that they see the advantage of 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 principles 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 packages like this.

HCI: You’ve added fairly a couple of totally different bundles through the years. Vanderbilt has developed bundles round maternity, listening to, backbone, orthopedics, weight reduction, urology, substance use dysfunction, and cardiology. Are there much more issues that may very well be put right into a bundle?

Cunningham: We now have that dialog loads. What’s the restrict of what might be bundled? I believe there are extra that may be. For those who’re acquainted with bundle packages, all people form of goes after the ortho stuff first. We figured that is what we might do. However then we began speaking with one in all 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 via with maternity and we discovered loads about methods to administer this and methods to change the definitions. We attempt to hearken to our employers and our companions and ask: The place are your ache factors and what do you want? We get loads of suggestions. I simply heard not too long ago that they need a diabetes bundle. There are packages that we are able to create which might be 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, had been there different well being programs across the nation additionally doing one thing related that you would mannequin your program after or had been you form of pioneering a few of this work?

Cunningham: 5 years in the past, I’d 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 targeted on procedures and never the excellent mannequin like we had been creating. After which there’s the Medicare mannequin. So these had been the 2 that we may have a look at, however not the best way that we needed to construction it, which is the extra complete expertise and the danger that we needed to tackle. I’ve talked to loads of establishments throughout the nation and extra try to get into this house and transfer within the course that we now have moved, which is nice. I like that there are extra folks desirous to do it. And a few are prepared to tackle the danger that we now have taken on, however I’d say that there is solely a handful.