Key Measures and Analytics in

Orthopedics

Mary Ann Clark, MHA

SVP Intralign

• Alignment of surgeons and

hospitals, clinical and operational

outcomes

• Integration of tools and

strategies in TJA to enhance

transparency and accountability

• Change Management -

Strength and capability to affect

lasting change for systems

seeking lasting change

Bending the cost curve Intralign’s innovative approach

Pre-OP Care: 3 -30 Days

(eg.)

Acute Phase*

Post-Acute: 30 - 180 Days (eg.)

Payer, Consumer, Employer Perspective

of Health Care Costs = Reimbursement

IntraoperativeRest of Acute Phase

2% 35% 38% 25% = 100%

* Acute Phase includes both facility and physician costs.Implant = 60% of

OR Costs

Total Episode Costs =

$22,000 - $32,000

Variation in Implant Costs and Total

Inpatient Costs is Significant

Addressing Drivers of OR Costs can Produce

‘Quick Wins’…

Rectifying Operational and Clinical

Inefficiencies

Hospital Cost Drivers

• Implant Cost

• Cutting Accessories

• Cement Accessories

• PAT and SPD

• Environmental Protection

• Patient-Specific CuttingBlocks

• Navigation

• Device Complexity

Process transformation

and supply chain

solutions add efficiencies.

Highly qualified clinical

staff increases

throughput, reduces costs

and increases quality.

The Role of the Sales Rep

• Lack of price

transparency and rep

presence leads to

unnecessary up-sell

• Rep or multiple reps

in OR slows room

turnover

• Clinical support

provided by the rep is

not free – charged

through hefty SG&A

implant cost

Influencing the Cost of Orthopaedic Implants

The result: Loss of control, reduced efficiency and higher supply costs.

Intralign’s Rep-less Assessment

Identify where Hospital is on the “Rep-less Roadmap” related to:

Reliance on the sales rep

Surgeon alignment

Staff capabilities

Implant and supply management

Vendor contract management

Quantify the potential benefits (financial and operational) of adopting a Rep-less model

Potential dollars saved per procedure

Financial benefits resulting fromstandardized processes

Objectives

Session Overview

• Why Measure?

• What to Measure?

• Resources, Tools, Measure Alignment/harmonization

• Measure development

• A Framework for Performance Measurement in

Orthopedics

• Measure Development and Implementation

• Managing Change and Improving Performance

in the Orthopedic Service Line – Case Studies

Regulation

Quality

Outcomes

Reimbursement

Satisfaction

Market Influences

Consumerism

Satisfaction

Market Share

Internal Operations

Costs

Revenue Cycle

Efficiency

Processes

MissionQuality

Outcomes

Why do

we need

to

measure?

“If you can’t

measure it,

you can’t

improve it.” –

Peter Drucker

External

Internal

CMS Program # Measures in FY 2015 Measure Types

Value-Based Purchasing 23 (# related to TJA = 15) Process, Outcomes, Patient

Experience, Efficiency

Readmission Reduction 5 (1 pertinent to TJA) All-cause TJA readmissions

within 30 days

Hospital Acquired Conditions

(HAC)

3 (All pertinent to TJA) CLABSI, CAUTI, Patient Safety

Composite Measure

CMS - Monitoring and Managing Key TJA

Cost, Quality, Operational and Patient

Satisfaction Measures to Achieve Value

Many more measures for quality reporting.

How does VBP impact hospital reimbursement?

25%

45%

30% 30%

20%2…

30%

Outcomes (Mortality)

Process Measures

Patient

Experience (HCAHPS)

REIMBURSEMENT

Process Measures

(New) Efficiency (Medicare

Spending)

REIMBURSEMENT

Outcomes Measures

• i.e. Acute Myocardial Infarction

Process Measures

• i.e. Prophylactic antibiotics given 48 hrs. before

surgeryPatient Experience Measures

• i.e. Communication with nurses

Efficiency Measures

• i.e. Medicare spending per beneficiary

2014 2015

Patient

Experience (HCAHPS)

Outcomes (Mortality)

Outcomes Measures

• i.e. Acute Myocardial Infarction

Process Measures

• i.e. Prophylactic antibiotics given 48 hrs. before

surgeryPatient Experience Measures

• i.e. Communication with nurses

Shifting focus on outcomes

and efficiency measures

Clinical and Operational Improvement

“It’s not a matter of whether orthopaedic surgeons want to have measures of accountability and improvement in defining their performance,” he said. “Orthopaedic surgeons are being rated today by a number of different stakeholders.” – Kevin Bozic, MD, MBA – Orthopedic Surgeon and Health Policy expert, UCSF

“We’ve been doing performance measures in a way for many years, beginning with process measures on issues such as antibiotic administration…. The trend now, as propelled by CMS and other payers, is toward use of subjective patient-reported outcomes. They want to know how the interaction with the doctor or surgeon went and how the surgery went.” –David A. Halsey, MD.

Identifying Key Measures

• Processes, utilization, and outcomes

• Target audiences/Users?

• Importance to measure and report

• Ability to interpret and act on findings

• Feasibility to measure

• Identifiable and measurable denominators

Example Resources for Orthopedic Measures

CMS/Commercial Payers – Quality – process of carereporting; Outcomes – complications, readmissions,mortality, hospital acquired conditions; patient satisfaction;volume thresholds

Registries – AHRQ-FORCE Registry – clinical outcomes,PROs, costs; California Joint Replacement Registry

Societies/Associations – AAOS (outcomes), HFMA (financial,revenue cycle)

Research Groups – AHRQ, Robert Wood JohnsonFoundation, NQF – outcomes, cost (payer perspective),quality

Literature – Operating Room efficiency measures

Other Hospitals – internal efficiency

Create your own, tailored to your institution’s needs

A Framework for Key Measures in Orthopedics – Balance

is Key

• Procedure Volume

• Avg. Age, Age Distribution, Sex

Distribution, Ethnicity Distribution

• Avg. Charlson Score

• ASA Category Distribution

• Payer Mix

• DRG Mix

• Surgeon Mix, Others

Patient Demographics

• Avg. Cost

• Avg. Reimbursement

• Avg. Net Revenue

• Procedure Volume

• Supplies, implantables Costs,

Others

Financial Impact

• Composite Event Rate

• Joint/Wound Infection Rate

• DVT/PE Rate

• Mechanical Complication Rate

• ALOS

• % Admitted to ICU

• % Discharged to Home/Self Care

• % with Spinal Anesthesia, Others

Quality and Outcomes

• Overall Efficiency Score

• Contribution Margin per OR Hour

• Avg. Case Duration

• Avg. Case Duration Prediction Bias

• Avg. Turnover Time, Others

Operational Efficiency

Patient

Satisfaction

Importance of Key Measures in Orthopedics:

Key Stakeholder Perspectives

4.67

4.93 4.87

4.47

4.71

3.07

4

4.64.4

4

3.27

3.53

4.734.53

4.93

3.873.85

2.46 2.38

3.08

0

1

2

3

4

5

6

Administrator Clinician Patient Payer

Ratin

g

Key Stakeholder Perspective

Quality and Outcomes Financial Operational Efficiency Patient Satisfaction Demographics/Stratification

Example Key Measure Specification

Measure Name: #358 Patient-centered Surgical Risk Assessment and Communication

Description: Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

Numerator: Documentation of empirical, personalized risk assessment based on the patient’s risk factors with a validated risk calculator using multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient and/or family

Denominator: The total number of adult patients (age 18 and over) having had non-emergency surgery

Exclusions: None

Measure Type: Process

Measure Steward: American College of Surgeons

http://riskcalculator.facs.org/

Potential data needed for Key Measure Calculations

UB-04 Scheduling OR-Anesthesia LogOperative

Note/Implant Log

Cost Accounting/

Supply Chain

• Unique Patient Billing

Identifier

• Unique Patient Medical

Identifier

• Hospital Admission

Date

• Hospital Discharge

Date

• ICU Admission Date

• ICU Discharge Date

• MS-DRG

• ICD-9 Diagnosis

Codes 1 - XX

• ICD-9 Procedure

Codes 1 - XX

• Admission Source

• Discharge Destination

• Payer

• Total Charges

• Total Reimbursement

• Patient Responsibility

• Revenue Center Code

• Charge Code

• HCPCS Code

• OR / Room

Identifier

• Case Identifier

• Block Allocation

• Cancellation

Status

• Cancellation Date

• Scheduled Case

Start (Wheels In)

• Scheduled Case

End (Wheels Out)

• Unique Patient Billing Identifier

• Unique Patient Medical Identifier

• OR Suite / Room Identifier

• Primary Surgeon

• Anesthesiologist

• Number of RNs

• Number of Surgical Technicians

• Sales Representative

• Surgical First Assist

• Operative Date

• Anesthesia Induction

• Anesthesia Ready

• Wheels In - Actual

• Surgeon In

• Surgical Incision

• Surgical Close

• Patient Wake

• Surgeon Out

• Wheels Out - Actual

• Start Clean

• End Clean

• Admission to PACU

• Tourniquet Time

• ASA Score

• Unique Patient

Medical Identifier

• Procedures

Performed

• Implants used

• Cement Fixation

• Antibiotic Cement

• Bone Morphogenic

Protein

• Anesthesia Type

• Estimated Blood Loss

• Complications

• Surgical Approach

• Operative Site

(right/left)

• Infection Prophylaxis

Protocol Followed

• DVT Prophylaxis

Protocol Followed

• Patient Surgical Prep

Protocols

• Unique Patient

Billing Identifier

• Cost

• Contract Status

• Contract Initiation

• Contract Renewal

• Internal

Identification Code

• Manufacturer

• Manufacturer

Catalog Number

• Vendor

• Vendor Catalog

Number

• Description

• Quantity

Potential Data Sources

Orthopedic Key

Measures

Claims Data Warehouse

Cost Accounting

System

Implant Logs

Device Manufacturer

Contracts

ORIS/AIS

Custom Data

Collection?

Post-op discharge

Surgeon’s Office SchedulingPre-Reg

PATPre-Op OR PACU

Inpatient Discharge

Post-acute care

Process of Care Transformations to Improve

Outcomes and Costs

Risk assessment and pre-admission

Scheduling and block time Surgical patient through-put

Communication hand-offs

Instrument flow

Assigned

Responsibility

Assigned

Responsibility

Assigned

Responsibility

Strategy Deployment

StrategyGoals /

DashboardKey Measures Projects

Patient Experience

Provider Satisfaction

Clinical Outcomes

Readmission Rates

Length of Stay

OR Turnover % Cases Cancelled

PACU Delays

Net revenue

Volume

Growth

Financial Operational

SatisfactionClinical

Vehicle for PI

and Strategy

Deployment

Training

Balanced Scorecard

Leading Lagging Indicators

Summary

• Consistent, substantiated data is a key factor in engaging physicians and staff to achieve success

• Plan for the long term• Success doesn’t happen overnight

• Build relationships with people who can help you• Many people are there to assist (both internal and

external), but you may have to search for them

• Communicate results regularly with front-line staff• They will be very engaged in the process

• They can have a big impact on achieving positive outcomes

• Don’t overlook small successes

For the presentation in full go to: http://www.intralign.com/library/resources/