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The Future of Patient Flow Management Practices in the New Era of Health Reform

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The Future of Patient Flow Management Practices in the New Era of Health Reform The Future of Patient Flow Management Practices in the New Era of Health Reform David J Yu, MD, MBA, FACP, SFHM Medical Director, Adult Inpatient Medicine Service Presbyterian Medical Group ACA: Affordable Care Act ACO: Accountable Care Organizations • “It is anticipated that ACOs will increasingly be reimbursed under a capitated model that incentivizes optimal quality, safety, efficiency, and health outcomes for populations of patients.” – J. Haugham, MD, D. Burton, MD, HealthCatalyst Value over Volume: Quality over Quantity • Revenue at Risk • Patient Experience • Complication Consequences • Population Health Medicare Advantage Enrollment Bundle Payments • Payment for Episodes of Care – Hospital cost – Professional fee: all physician charges – Ancillary Service – SNF, Rehab • Middle ground between FFS and Capitation • Based on delivering episode of care at a lower price Payment Transparency • Commercial Insurance % of Medicare • ? Demise of Hospital Chargemaster Revenue Center versus Cost Center Patient Flow Traditional View • ED Physician Process owner • Discharge before noon • Observation units • Push patients up to medicine / surgical floor • Hall beds in ED/ Floor Patient Flow: Age of ACA • “A comprehensive, strategic initiative that hospitals need to align all their clinical departments, departmental budgets, and administrative processes around to achieve.” – Today’s Hospitalist, October 2014, David Yu, MD Patient Flow as a Strategic Initiative • How do you model financial efficiency in a cost center model? • No revenue generation • wRVU becomes irrelevant • Cost Avoidance • Holy Grail: Better Quality at a Lower Cost • Political shift from revenue generators to process owners If the rate of change on the outside exceeds the rate of change on the inside, the end is near. Jack Welch, CEO, General Electric Form Follows Function Form Follows Function B-52 Linebacker II 1972, North Vietnam 10 planes shot down, 5 damaged B-2 Kosovo, Afghanistan, Iraq campaign No planes lost nor damaged The Land of Enchantment • Approximately 2 million people • 5th largest state in geographic area • Lowest Commercially Insured • 2nd Highest Medicaid • 2nd Highest Uninsured • Ranked 33rd in overall health status • 22 Sovereign Native American Tribes • Most PhDs per capita • 0 professional football teams Presbyterian Healthcare Services Hospitals • 8 hospitals in 7 communities • Total of 874 beds in New Mexico Health Plan • 445,00 members throughout NM • Largest Medicaid carrier • Largest Medicare Advantage carrier • 2nd largest Commercial carrier Medical Group • Multi-specialty group with 770 providers Hospitals • Operates approximately 90 clinics in 44 Outpatient Facilities Presbyterian Administration Center facilities Presbyterian Health Plan Membership Statewide Central New Mexico Presbyterian Healthcare Services • Gross Revenue $ 2.7 billion • Revenue at Risk $1.8 billion • Revenue Fee for Service $900 million Presbyterian Hospital • Albuquerque, New Mexico • Flagship hospital of PHS • Tertiary Center • 453 Licensed beds • Closed ICU with Intensivists 24/7 • Presbyterian Hospital ED 68,888 encounters 2013, 100,000 entire CDS Presbyterian Medical Group, PMG Adult Inpatient Medicine Service, AIMS Presbyterian Hospital • 50 FTE requirements • 60 + Hospitalist Attending • 8 RNs, Triage RNs, Cross Cover RNs • 17 Rounding Teams, 4 Admitting Swing Shifts, 3 Over Night Shifts, 2 Triage Shifts. • Presbyterian Hospital, Albuquerque, NM, Inner City Tertiary Center, 453 beds • AIMS performed 16,500 discharges 2013, 18,750 discharges in 2014 • Admits and discharges 80 to 150 patients per day. Peak volume records:85 admissions with H&P in a 24 hour period, 80 discharges in 12 hours. Prior to Patient Flow Process Journey • Left Without Being Seen Rate in Presbyterian Hospital ED >10% 2009 • Regional hospital transfers to PH took average days not hours, patients frequently transferred to Denver, Phoenix, El Paso, Amarillo • ED patient boarding • ED ambulance bypass • Adult Inpatient Medicine Service (AIMS) aLOS 5.06 in 2009 Hospitalist’s Contribution to Patient Flow: Reduction of aLOS Presbyterian Hospital ED LWBS 12% 10% 8% 6% 4% 2% 0% 2008 2009 2010 2011 2012 2013 2014 Year PMG AIMS Discharge per Month Discharges 2010 - 2015 1,900 1,800 1,700 2010 1,600 2011 1,500 2012 1,400 2013 1,300 2014 1,200 2015 1,100 1,000 900 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec PMG, AIMS: Bending Cost Curve Controllable Cost/Discharge $1,100 $1,050 $1,000 $950 Ave Ave Cost $900 $850 $800 2009 2010 2011 2012 2013 2014 2015 Year Patient Flow as an Integrated Process • Integrated processes • Breaking Down Financial Silo • “Sucks to be you!” –Principle. The system as a whole suffers. Individual departments rewarded. • “When there is no Vision, the People perish”. Proverbs, KJV. aLOS • Average Length of Stay and Budgeted Bed Capacity determines patient flow. • ED Flow = Upstairs bed availability • Hospitalists and Hospitalist Groups play a major role. • Ancillary Services, Specialists, Nursing, Care Coordination play critical role. • Rough proxy of variable cost per case. aLOS / Variable Cost per Discharge Not all aLOS is the same! • Patient A: Community acquired pneumonia. LOS 4 days, variable cost of hospitalization $8,500 dollars. • Patient B: Community acquired pneumonia. LOS 5 days, variable cost of hospitalization $2,500 dollars. • Which one would you choose? Variable Cost per Case • Tremendous Cost / Savings Effects • 20,000 discharges X _________ = • Ask CFO, “Do you want save a dollar or earn a dollar?” Data vs Analytics MPG versus Cents Per Ton Mile 4 mpg 5 cents per ton mile 38 mpg 52 cents per ton mile Discharge Efficiency • Discharge as a Percentage of Starting Census • Small change means huge difference – 20% aLOS 5.0 days – 23% aLOS 4.35 days (3%= 0.65 days reduction) – 25% aLOS 4.0 days Discharge Efficiency/ aLOS 4.9 29.00% 4.7 27.00% 4.5 25.00% 4.3 23.00% aLOS Discharge Efficiency 4.1 21.00% 3.9 19.00% 3.7 17.00% 3.5 15.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Census per Team / Discharge 15 28.0% 27.0% 14 DC/ Starting Census % 26.0% 25.0% 13 24.0% 12 23.0% 22.0% Starting Census Average 11 per Team 21.0% 20.0% 10 19.0% 9 18.0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec AIMS Average Starting Census per Team Average Team Census 2014 Average of Starting Census Month Grand Team Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Diamond 16.00 14.32 14.68 14.77 14.16 16.16 12.35 11.94 11.80 12.58 13.13 13.61 13.71 Emerald 13.77 13.43 12.77 13.10 13.79 14.00 12.21 12.26 12.47 13.03 12.43 13.23 13.04 Gold 14.32 12.11 13.45 12.97 11.84 14.37 11.29 11.10 11.00 12.65 12.03 13.55 12.54 Gray 15.74 14.04 11.93 13.13 12.10 13.47 11.32 10.45 11.30 12.74 12.58 14.48 12.77 Green 14.68 14.18 12.68 13.32 13.16 12.46 13.19 11.55 11.63 13.00 13.48 13.16 13.04 Indigo 13.48 12.75 12.42 12.70 13.23 12.87 11.45 11.29 11.70 13.48 13.10 12.58 12.59 Jemez 14.10 12.86 12.97 12.55 11.68 12.83 11.10 12.32 11.20 12.10 11.47 13.00 12.35 Lavender 13.93 12.86 13.13 12.46 13.06 15.70 11.71 12.06 12.00 13.00 12.13 12.39 12.87 Pecos 13.48 13.04 12.90 12.47 11.59 13.37 11.26 10.87 10.60 12.68 11.30 12.29 12.15 Platinum 14.26 12.82 12.03 11.83 12.13 14.50 11.29 10.71 10.80 12.68 12.13 12.84 12.33 Purple 13.42 12.86 13.00 12.60 13.42 14.83 12.16 12.94 11.77 12.90 12.40 12.48 12.90 Ruby 14.71 13.00 12.68 12.87 13.10 14.17 11.61 11.32 11.50 12.90 12.53 12.65 12.75 Sandia 13.55 11.43 12.45 13.30 12.94 12.83 12.10 10.29 10.17 12.00 11.10 12.84 12.09 Silver 13.71 12.11 12.39 13.87 10.10 13.37 11.00 11.10 11.07 13.00 11.87 11.52 12.09 Steel 8.45 5.54 6.23 6.07 6.03 6.00 5.61 5.52 5.37 5.32 5.30 5.29 5.90 Topaz 14.06 13.64 12.68 12.25 12.32 14.00 11.48 11.06 11.27 13.10 11.87 14.19 12.64 Violet 14.65 13.43 13.71 12.50 11.84 14.57 12.16 11.55 12.30 12.77 11.97 12.19 12.80 White 13.82 14.58 11.74 14.17 11.10 13.16 Grand Total 13.90 12.68 12.60 12.48 12.25 13.44 11.37 11.08 11.06 12.35 11.80 12.49 12.28 Inpatient Days Per Rounding Team • New metric to measure productivity and patient turnover • Nursing midnight census • Census average for hospitalist aLOS per Month AIMS aLOS Admission and Obs 4.80 4.60 2011 4.40 2012 2013 4.20 2014 2015 4.00 3.80 3.60 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Year end aLOS Patient Experience Score Ranking Perverse Incentive, Unintended Consequences: The Great Hanoi Rat Massacre Hospitalist Perverse Incentive Not to Discharge: wRVU Trap • Hospitalist enjoy high compensation but work load is unstainable, with daily census 20 to 28 patients to maximize wRVU • Specialist centered • Level loading census • Caps • High census leads to discharge inefficiency Increased Hospitalist Workload leads to Increase Length of Stay • Increasing Hospitalist Workload Linked to Longer Length of Stay, Higher Costs – Elliot D, et al, JAMA.
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