Providers Using Bundled Payments, Quality to Entice Employers
By bundling all costs for the surgery under one negotiated price and offering expertise that lowers the odds of complications, the Cleveland Clinic gave Bumbaugh and his employer a better deal than the hospital close to his home.
(Bloomberg) -- In the changing world of health care, patients are finding that the best care may be several hundred miles away.
When Travis Bumbaugh needed heart surgery, the Pennsylvania general contractor chose the cheapest option in the Lowes Cos. health plan. He flew to Cleveland, to one of the top-rated heart hospitals in the nation.
By bundling all costs for the surgery under one negotiated price and offering expertise that lowers the odds of complications, the Cleveland Clinicgave Bumbaugh and his employer a better deal than the hospital close to his home. In some cases, hospitals will drop their prices as much as 40 percent to guarantee a steady stream of patients they wouldnt have otherwise, said Terry White, president of the BridgeHealth Medical Inc., a Denver-based benefit manager.To encourage employees, Lowes covers the full cost of surgery, as well as travel and lodging for the worker and a relative. The company health plan wont cover thousands of dollars of unbundled costs at local hospitals.
Its a win-win-win for patients, employers and the hospital, said Michael McMillan, Cleveland Clinics executive director of market and network services. The patient has no out-of-pocket responsibility, employers have a better long-term financial result and we get patients.
U.S. employers are seeking innovative ways to trim health expenses as costs rise and the government mandates broader coverage for employees under the Patient Protection and Affordable Care Act. Medical centers, meanwhile, get an extra burst of patients at a time when hospitals nationwide are struggling with sluggish volumes in a tough economy and cutting jobs. Last year, the Cleveland Clinic closed several hundred open positions and gave 700 workers early retirement, citing pressures of health-care reform.
200 surgeries
The Clinic, an early pioneer in offering flying-surgery care, has partnerships with more than a half-dozen large employers and has completed about 200 surgeries in the program over the past three years, according to McMillan.
More recently, its been joined by other centers, including Johns Hopkins Bayview Medical Center in Baltimore, that see the same opportunities.
Its new volume that we wouldnt have otherwise, which means new revenue for us, Trisha Frick, assistant director of managed-care contracting at Johns Hopkins, said in a telephone interview. It also gives us predictability in reimbursement rates.
The fixed rate also provides incentive for both the hospital and its medical professionals to be more efficient, she said. If the hospital manages to save costs, it gets a higher profit margin from the agreed-upon reimbursement.
Extending Market
Providers are very interested in extending their market share nationally, said Susan Connolly, a partner at Mercer LLC who specializes in clinical consulting. Contracting with Lowes or Wal-Mart Stores Inc., you know youre going to get a lot of volume because theyre so big.
Lowes, based in Mooresville, North Carolina, employs 161,000 people. Other companies now using the travel surgery option are Wal-Mart, the biggest private employer in the U.S. with 1.3 million workers, and PepsiCo Inc., the worlds largest snack maker, with 106,000 U.S. employees.
Surgery costs can vary widely by hospital, making it tough for large companies to budget for health-care expenses. For instance, the price of a full-hip replacement ranges from $15,464 to $76,785, according to the pricing guide Healthcare Bluebook. By contracting for care at hospitals that agree to a bundled cost based on a set medical diagnosis, self-insured employers can better plan out their expenses based primarily on the number of employees they cover.
Lowes, the second-biggest U.S. home-improvement chain, was one of the first big companies to fly employees to the Cleveland Clinic for cardiac procedures, starting in 2011. Since then, more than 60 employees have taken part in the program, said spokeswoman Amanda Manna. She declined to say how much Lowes has saved in this time.
Wal-Mart instituted its own program last year. More than a million of the retailers employees and family members have opted to be covered by the plan, which flies them to six providers, including the Cleveland Clinic, Virginia Mason Medical Center in Seattle and Scott & White Memorial Hospital in Temple, Texas, for heart, spine and transplant surgery.
The program wasnt just about cost savings, said Randy Hargrove, a Wal-Mart spokesman.
We werent looking for a low-cost provider, Hargrove said in an e-mail. We identified high-quality providers and then developed a bundled payment to cover the entire episode. He, too, declined to comment on specific pricing.
In January, Wal-Mart added another program, joining Lowes and other companies in the Pacific Business Group on Health, a San Francisco-based nonprofit business coalition, that schedules hip and knee replacements with centers that include Johns Hopkins, and Kaiser Permanente in Irvine, California. PepsiCo and Boeing Co. have similar plans.
Big companies arent the only ones seeking to take advantage of the idea. Alliances such as the non-profit Employers Health Coalition, which represents about 300 companies, began a travel-surgery program last month for smaller employers, Bruce Sherman, the medical director for the Canton, Ohio-based group, said in a telephone interview.
It would be prohibitive for a small employer, with only one or two employees needing surgery a year, said Sherman, who declined to identify the companies and hospitals participating. When you spread the administrative costs over a number of employers, it becomes more attractive.
Complications, readmissions
Low rates of complications and readmissions are a big draw for employees seeking to partner with hospitals, said Mercers Connolly.
Its easy for the cost to exponentially increase if you have a readmission because when patients are readmitted, theyre pretty sick, she said. Doubling the cost of the first admission would not be a stretch.
Only 3 to 4 percent of travel surgery patients at the Cleveland Clinic have been readmitted in the last three years, said spokeswoman Heather Phillips. The Clinic tracks patients after they go home, allowing them to count readmissions to any hospital afterward, she said. Nationally, the average readmissions rate for heart surgeries is 9 to 13 percent, according to the Society of Thoracic Surgeons.
Once a travel program is set in place, employers have one more challenge: getting employees to sign on.
Many workers have a fairly close bond with their own personal physicians and may not be particularly interested in traveling a great distance from their own location, even if the quality is substantially better, said Sherman, of the Employers Health coalition. Employees can sometimes be nervous about traveling or recuperating far from home.
Many of them have never been on a plane, Ruth Coleman, chief executive officer of third-party administrator Health Design Plus in Hudson, Ohio, said in a telephone interview.
Bumbaugh, an exteriors specialist from Chambersburg, Pennsylvania, wanted his wife with him when he went for surgery to repair a heart valve. A Lowes employee for 13 years, Bumbaugh manages home-improvement projects like windows and fencing installation and roofing.
Four years ago, at age 38, he was told that a valve in his heart wasnt closing properly and was leaking blood. Bumbaugh knew he would eventually need surgery and began researching his options, comparing the Lowes travel surgery program with the offerings at his local hospital.
Mortality rate
One thing that really struck me about Cleveland was that their mortality rate was less than 1 percent, he said in a telephone interview. Everything else I was seeing was 1 to 2 percent higher, which is not a lot ... but still.
Doctors at Cleveland Clinic also said they could repair his valve instead of replacing it, something that the local Harrisburg Hospital couldnt do. What finally tipped the scales, though, was the financial incentive Lowes provided for using the Cleveland Clinic, Bumbaugh said.
If he went to the nearby Harrisburg Hospital, he estimated he would have paid about $10,000 in out-of-pocket costs. By using the Cleveland Clinic, he didnt pay a dime. Lowes covered everything, including his wifes travel and lodging.
Knowing I didnt have to come home and worry about bills mounting up, I had to take advantage of the opportunity, Bumbaugh said.
Harrisburg Hospital, run by PinnacleHealth System, is confident that we compare favorably to Cleveland Clinic on cost and quality, spokeswoman Kelly McCall said in an e-mail.
The hospital is considering offering the same service for large employers, she said: We are open to working with employers so that their employees can access our quality care close to home.
Successful surgery
Bumbaugh and his wife, Barbara, traveled to Cleveland in October 2012. The surgery was successful and he had no complications.
While major issues like pricing and Cleveland Clinics reputation spurred Bumbaugh to leave home, he said its the little things that he remembers most fondly.
It sounds little off the wall, but even the gentleman with the valet parking would ask my wife how I was doing, he said. And the hospital liaison between Lowes and Cleveland Clinic came and sat with my wife during my surgery. Youre not just a number, so to say. They look at you as a human being.
Its a win-win-win for patients, employers and the hospital, said Michael McMillan, Cleveland Clinics executive director of market and network services. The patient has no out-of-pocket responsibility, employers have a better long-term financial result and we get patients.
U.S. employers are seeking innovative ways to trim health expenses as costs rise and the government mandates broader coverage for employees under the Patient Protection and Affordable Care Act. Medical centers, meanwhile, get an extra burst of patients at a time when hospitals nationwide are struggling with sluggish volumes in a tough economy and cutting jobs. Last year, the Cleveland Clinic closed several hundred open positions and gave 700 workers early retirement, citing pressures of health-care reform.
200 surgeries
The Clinic, an early pioneer in offering flying-surgery care, has partnerships with more than a half-dozen large employers and has completed about 200 surgeries in the program over the past three years, according to McMillan.
More recently, its been joined by other centers, including Johns Hopkins Bayview Medical Center in Baltimore, that see the same opportunities.
Its new volume that we wouldnt have otherwise, which means new revenue for us, Trisha Frick, assistant director of managed-care contracting at Johns Hopkins, said in a telephone interview. It also gives us predictability in reimbursement rates.
The fixed rate also provides incentive for both the hospital and its medical professionals to be more efficient, she said. If the hospital manages to save costs, it gets a higher profit margin from the agreed-upon reimbursement.
Extending Market
Providers are very interested in extending their market share nationally, said Susan Connolly, a partner at Mercer LLC who specializes in clinical consulting. Contracting with Lowes or Wal-Mart Stores Inc., you know youre going to get a lot of volume because theyre so big.
Lowes, based in Mooresville, North Carolina, employs 161,000 people. Other companies now using the travel surgery option are Wal-Mart, the biggest private employer in the U.S. with 1.3 million workers, and PepsiCo Inc., the worlds largest snack maker, with 106,000 U.S. employees.
Surgery costs can vary widely by hospital, making it tough for large companies to budget for health-care expenses. For instance, the price of a full-hip replacement ranges from $15,464 to $76,785, according to the pricing guide Healthcare Bluebook. By contracting for care at hospitals that agree to a bundled cost based on a set medical diagnosis, self-insured employers can better plan out their expenses based primarily on the number of employees they cover.
Lowes, the second-biggest U.S. home-improvement chain, was one of the first big companies to fly employees to the Cleveland Clinic for cardiac procedures, starting in 2011. Since then, more than 60 employees have taken part in the program, said spokeswoman Amanda Manna. She declined to say how much Lowes has saved in this time.
Wal-Mart instituted its own program last year. More than a million of the retailers employees and family members have opted to be covered by the plan, which flies them to six providers, including the Cleveland Clinic, Virginia Mason Medical Center in Seattle and Scott & White Memorial Hospital in Temple, Texas, for heart, spine and transplant surgery.
The program wasnt just about cost savings, said Randy Hargrove, a Wal-Mart spokesman.
We werent looking for a low-cost provider, Hargrove said in an e-mail. We identified high-quality providers and then developed a bundled payment to cover the entire episode. He, too, declined to comment on specific pricing.
In January, Wal-Mart added another program, joining Lowes and other companies in the Pacific Business Group on Health, a San Francisco-based nonprofit business coalition, that schedules hip and knee replacements with centers that include Johns Hopkins, and Kaiser Permanente in Irvine, California. PepsiCo and Boeing Co. have similar plans.
Big companies arent the only ones seeking to take advantage of the idea. Alliances such as the non-profit Employers Health Coalition, which represents about 300 companies, began a travel-surgery program last month for smaller employers, Bruce Sherman, the medical director for the Canton, Ohio-based group, said in a telephone interview.
It would be prohibitive for a small employer, with only one or two employees needing surgery a year, said Sherman, who declined to identify the companies and hospitals participating. When you spread the administrative costs over a number of employers, it becomes more attractive.
Complications, readmissions
Low rates of complications and readmissions are a big draw for employees seeking to partner with hospitals, said Mercers Connolly.
Its easy for the cost to exponentially increase if you have a readmission because when patients are readmitted, theyre pretty sick, she said. Doubling the cost of the first admission would not be a stretch.
Only 3 to 4 percent of travel surgery patients at the Cleveland Clinic have been readmitted in the last three years, said spokeswoman Heather Phillips. The Clinic tracks patients after they go home, allowing them to count readmissions to any hospital afterward, she said. Nationally, the average readmissions rate for heart surgeries is 9 to 13 percent, according to the Society of Thoracic Surgeons.
Once a travel program is set in place, employers have one more challenge: getting employees to sign on.
Many workers have a fairly close bond with their own personal physicians and may not be particularly interested in traveling a great distance from their own location, even if the quality is substantially better, said Sherman, of the Employers Health coalition. Employees can sometimes be nervous about traveling or recuperating far from home.
Many of them have never been on a plane, Ruth Coleman, chief executive officer of third-party administrator Health Design Plus in Hudson, Ohio, said in a telephone interview.
Bumbaugh, an exteriors specialist from Chambersburg, Pennsylvania, wanted his wife with him when he went for surgery to repair a heart valve. A Lowes employee for 13 years, Bumbaugh manages home-improvement projects like windows and fencing installation and roofing.
Four years ago, at age 38, he was told that a valve in his heart wasnt closing properly and was leaking blood. Bumbaugh knew he would eventually need surgery and began researching his options, comparing the Lowes travel surgery program with the offerings at his local hospital.
Mortality rate
One thing that really struck me about Cleveland was that their mortality rate was less than 1 percent, he said in a telephone interview. Everything else I was seeing was 1 to 2 percent higher, which is not a lot ... but still.
Doctors at Cleveland Clinic also said they could repair his valve instead of replacing it, something that the local Harrisburg Hospital couldnt do. What finally tipped the scales, though, was the financial incentive Lowes provided for using the Cleveland Clinic, Bumbaugh said.
If he went to the nearby Harrisburg Hospital, he estimated he would have paid about $10,000 in out-of-pocket costs. By using the Cleveland Clinic, he didnt pay a dime. Lowes covered everything, including his wifes travel and lodging.
Knowing I didnt have to come home and worry about bills mounting up, I had to take advantage of the opportunity, Bumbaugh said.
Harrisburg Hospital, run by PinnacleHealth System, is confident that we compare favorably to Cleveland Clinic on cost and quality, spokeswoman Kelly McCall said in an e-mail.
The hospital is considering offering the same service for large employers, she said: We are open to working with employers so that their employees can access our quality care close to home.
Successful surgery
Bumbaugh and his wife, Barbara, traveled to Cleveland in October 2012. The surgery was successful and he had no complications.
While major issues like pricing and Cleveland Clinics reputation spurred Bumbaugh to leave home, he said its the little things that he remembers most fondly.
It sounds little off the wall, but even the gentleman with the valet parking would ask my wife how I was doing, he said. And the hospital liaison between Lowes and Cleveland Clinic came and sat with my wife during my surgery. Youre not just a number, so to say. They look at you as a human being.
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