Some employers are beginning to contract directly with healthcare provider organizations. To partner with self-insured employers, Nashville-based Vanderbilt University Medical Center has developed value-based care bundled payment programs for some of the most common and costly health conditions, such as maternity, orthopedics and cardiology. Healthcare innovation I recently spoke with Brittany Cunningham, DNP, MSN, RN, who has led efforts to launch and expand VUMC’s direct-to-employer commercial packages with the goal of offering predictable pricing and concierge-level experience for patients, while saving money for employers and patients. .
HCI: Your title is vice president of the Office of Population Health Care Episodes at Vanderbilt. Could you tell us a little about his experience in nursing and how he came to lead this program?
Cunningham: When I think back, I never imagined I would be doing something like this. I didn’t even know it existed when I started nursing twenty-something years ago. I have been at Vanderbilt for 22 years. I was a quality and patient safety advisor for the Heart Institute. As CMS began to focus more on value-based care and decreasing costs and increasing quality, I was in a position to really focus on that work. I was responsible for reportable outcomes, decreasing readmissions, and then CMS started piloting programs like bundled payment care initiatives. Vanderbilt wanted to pilot that program and that was part of my responsibility. That’s how I first tried bundled payments. Then Vanderbilt said we needed to start focusing more on this. I started this office in 2015. At one time we served over 40 populations with Medicare. The state of Tennessee also offers Medicaid episodes of care. Then we started focusing on direct-to-employer business populations in 2018 and then really ramped it up in 2019 and went live in 2020. We took our experiences from the government side and translated them to the business side and developed them ourselves.
HCI: Is there a difference between how packages are made directly to the employer and how packages are made in Medicaid or Medicare?
Cunningham: There are some similarities, but I think the biggest difference is the way we have structured our definitions. We go directly to our doctors and tell them: don’t worry about the payer. We are very clinically focused. We let them decide how they want to provide patient care and what they think is the best evidence-based care. Then we built a payment model around it. With Medicare and Medicaid, they come to us as payers and are trying to cut costs out of the system, and then we have to provide the underlying clinical care. So we’re turning it around. We say what the best possible clinical care is and then we implement a payment model for it.
HCI: Is one of the goals to eliminate clinical variation? Do doctors have to agree on what is the best thing they can do based on the evidence and then everyone in the department will follow that?
Cunningham: Yes absolutely. Everyone has to accept this path. A great example is cesarean sections. For our maternity package, we have a combination of cesarean and vaginal rates. We have a price for that together, so it’s a fixed utilization rate. So if you exceed that utilization, you won’t get paid more. We’re not going to pay for C-sections just to have a C-section, which is the fee-for-service model. We’re really taking away that incentive for providers to do something just for the sake of doing it.
HCI: But does that lead to interesting conversations between doctors as they try to reach an agreement?
Cunningham: That’s a really interesting question. We are talking to a new group of providers about the C-section conversation and they are very excited because they feel like some payers are penalizing them for their C-section rate. In fact, we’re incentivizing them to do the right thing, meaning if you don’t have to do a C-section, we’re going to incentivize you not to do that C-section, where there are payers that are just lowering that target C.-sections and not incentivizing them to do the right thing. correct.
HCI: Is one aspect of this improved communication with patients, perhaps more digital communications so they are clear about what to expect to happen during the episode?
Cunningham: When creating the package, we really focused on three different parts. We focus on clinical care. We focus on the financial part, which is that payment model and it is a fixed price, so there is predictability for the employer and transparency for that.
The other key part is that we give up the patient portion, so we also provide cost savings to the patient. And then we focus on the experience. How do we make this a better patient experience? We didn’t want to just put lipstick on a pig. In fact, we wanted it to be a better experience. We added patient navigators, who guide patients through the package. For maternity, a package can last up to 12 months, so it is important to understand what is included and what is not. The navigator is there for any non-clinical questions. The patient can call for directions and schedule an appointment. For any questions, they have that single point of contact. The navigator will send information to the patient at key points during the package and during the trip. So instead of giving an educational book and a lot of information, they will send little emails or little snippets of information at key points. We break it down so as not to overwhelm the patient and it really helps them understand what to expect.
HCI: Have you collected patient-reported outcomes data on the back end to compare to a control group of people who are not in a program like this?
Cunningham: We collect patient-reported functional outcomes for our orthopedic patients, but we have not yet performed that comparison to determine whether patient-reported outcomes are different than those for non-bundle patients. I think that’s in our future. We have survey data, which is patient satisfaction data. Our Net Promoter Score is extremely high. We are in the eighties and we have been like this for a couple of years now. We also have outcome data such as cesarean section rates. Our C-section rates are lower than patients who do not receive the package. Another interesting fact is that our NICU rates are lower.
HCI: Can you measure employer satisfaction, either through continued participation or growth in the program?
Cunningham: We’ve had some key employers from the beginning. We currently have five employers with contracts. Those employers who have been with us from the beginning have added more programs. One employer said he wanted to start with maternity and then, about six months later, he said they were going to add more programs. We just talked to them recently and they are interested in adding even more programs, so they see the benefit and they see that their members appreciate it.
HCI: Do the employers you work with have to be self-insured?
Cunningham: They have to be self-insured. And the reason is that there are rules between self-insured and fully insured. Full insurance isn’t as flexible, but with self-insurance, you’re basically writing your own rules for your benefits and you can be more flexible by adding value-based programs like this one.
HCI: You’ve added quite a few different packages over the years. Vanderbilt has developed packages on maternity, hearing, spine, orthopedics, weight loss, urology, substance use disorders, and cardiology. Are there even more things that could be included in a package?
Cunningham: We have that conversation a lot. What is the limit of what can be grouped? I think there are more that could be. If you’re familiar with package programs, everyone looks for ortho stuff first. We thought that’s what we would do. But then we started talking to one of our employer partners and he told us that what they needed was maternity. Motherhood was where her high expense and variability was. They needed help with that, so we pivoted and tackled motherhood first, which was very beneficial because it was 2019. And we started in 2020. That’s when COVID hit, and we continued doing orthopedics right after that. We had a lot of volume on motherhood and we learned a lot about how to manage this and how to change definitions. We try to listen to our employers and partners and ask them: Where are their pain points and what do they need? We received many comments. I recently heard that they want a diabetes package. There are programs we can create that are value-based to help with their expenses and provide a better patient experience.
HCI: Around the time Vanderbilt was starting to do this work, were there other health systems around the country also doing something similar that you could model your program after or were you a pioneer in this work?
Cunningham: Five years ago, I’d say, there weren’t many out there. There were a couple that did more of the “centers of excellence” model, which really focuses on procedures and not the end-to-end model like we were creating. And then there’s the Medicare model. So those were the two we could look at, but not the way we wanted to structure it, which is the most complete experience and the risk we wanted to take. I’ve talked to a lot of institutions around the country and there are more that are trying to get into this space and move in the direction that we’ve been moving in, which is fantastic. I love that there are more people wanting to do it. And some are willing to take the risk that we have taken, but I would say they are only a few.
