Some employers are starting to contract immediately with supplier organizations for healthcare. To accomplice with self-insured employers, Nashville-based Vanderbilt College Medical Middle has developed value-based care bundled cost applications for among the most typical and dear well being situations, resembling 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 business bundles with the objective 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 below  Inhabitants Well being at Vanderbilt. May discuss slightly bit about your nursing background and the way you got here to guide this program?

Cunningham: After I assume again, I by no means imagined that I might be doing one thing like this. I did not even realize it existed once I obtained 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 reducing price and rising high quality, I used to be able to actually give attention to that work. I used to be accountable for reportable outcomes, reducing readmissions, after which CMS began piloting applications like bundled cost care initiatives. Vanderbilt wished to pilot that program and that was a part of my accountability. That is how I obtained 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 business 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 business 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 largest distinction is the way in which that we’ve structured our definitions. We go on to our clinicians and say, don’t be concerned in regards to the payer. We’re very clinically targeted. We allow them to resolve the way in which they wish to present the take care of the affected person, and what they really feel is finest 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’ve to supply the medical care beneath it. So we’re flipping it round. We are saying what’s the finest medical care potential — after which we put a cost mannequin round it.

HCI: Is among the objectives eliminating medical variation? Do clinicians need to agree on what the perfect evidence-based factor to do is after which everybody within the division goes to comply with that?

Cunningham: Sure, completely. Everybody has to comply with this pathway. A very 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 charge. So in the event 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 extremely attention-grabbing query. We’re speaking to a brand new supplier group in regards to 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 charge. We are literally incentivizing them to do the best factor, which is that if you do not have to do a C-section we are going to incentivize you to not try this C-section, the place there are payers which might be simply ratcheting down that objective of C-sections and never incentivizing them to do the best 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 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 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 wish to simply put lipstick on a pig. We wished to really make it a greater expertise. We added affected person navigators, who stroll sufferers via 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 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 data to the affected person at key factors throughout the bundle and throughout the journey. So as a substitute of giving a guide of training 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 end result information 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’ve 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 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 via continued participation or progress in this system?

Cunningham: We have had just a few key employer for the reason that starting. We presently 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 wished 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 not too long ago and so they’re considering including much more applications, so that they see the advantage of it and so they 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. totally insured. Totally insured shouldn’t be as versatile, however with self-insured, you’re basically writing your personal guidelines of your advantages, and you may be extra versatile with including value-based applications like this.

HCI: You’ve added fairly just a few 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 could possibly be put right into a bundle?

Cunningham: We now have that dialog quite a bit. What’s the restrict of what could be bundled? I believe there are extra that may be. In case you’re conversant in bundle applications, everyone type of goes after the ortho stuff first. We figured that is what we’d do. However then we began speaking with one in all our employer companions and so they 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 helpful 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 realized quite a bit about easy methods to administer this and easy 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 a number of suggestions. I simply heard not too long ago that they need a diabetes bundle. There are applications that we will 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 in regards to the time Vanderbilt was beginning to do that work, have been there different well being techniques across the nation additionally doing one thing related that you can mannequin your program after or have been you type 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 absolutely targeted 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 way in which that we wished to construction it, which is the extra complete expertise and the chance that we wished to tackle. I’ve talked to a number of establishments throughout the nation and extra are attempting to get into this area and transfer within the path 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.