Bundled payments bring both risk and opportunity


Here’s how bundled payments work.  CMS sets a target price for a medical or surgical episode.  It pays providers on a fee for service basis through the course of care but after a certain amount of time the total cost of care is reconciled with the target amount.  Hospitals get to pocket the difference or pay back the amount it cost to provide care for the patient above the target.  Hospitals are “on the hook” for the cost of services provided within their facility and the cost of care when the patient leaves their four walls for a designated amount of time.  This model requires hospitals to carefully control cost for services they provide and identify low cost providers to meet the patients needs once the patient leaves their facility.

Around a year ago CMS launched a bundled payment initiative for hospitals and ambulatory surgical centers that perform hip and knee replacements in certain areas of the country.  The bundled payment program was launched as a demonstration and certain geographic areas were included.  The bundled payment program pays the hospital on a fee for service basis for the surgery and any other services provided to the patient that relate to the joint replacement.  Any additional services the patient needs for 90 days following the surgery are also tracked.  Most patients who have an elective joint replacement will need either a skilled nursing stay or home health and many will then progress to outpatient rehab.  Once 90 days passes the hospital where the surgery was performed gets to pocket some money or pay back the difference.  You can see how hospitals have real incentive to reduce cost and identify low cost, high quality, post acute services.

CMS has now proposed bundled payments for three new episodes including heart attack, coronary artery bypass and hip fracture.  The three diagnosis I just mentioned really raise the stakes and the difficulty in controlling cost.  Elective joint replacements are just that, elective.   Surgeons and hospitals can be selective about who they provide services to.  If a patient is high risk or has other underlying health concerns a decision can be made to not provide the service.  Heart attacks and hip fractures are different.  No one plans to have a heart attack or fracture a hip.  Patients who have these diagnosis are generally high risk and they tend to have complications because of comorbidities.

Bundled payments provide a lot of incentive for hospitals to reduce cost.  It’s easier to reduce cost when the patient population is hand picked.  The newly proposed expansion to bundled payments increases the complexity in controlling cost exponentially.



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Being better, doing better, helps our patients get better

Quality Billboard

Our Mission is to provide exceptional health and wellness services with friendliness and compassion and we devote most of our time and resources to helping people get better.  When we help people get better we’re not only helping the sick become well but we help the healthy learn how to get healthier.

This next week we have an opportunity to help our organization get better.  Beginning Monday, September 12, GVMH will host a site visit for a team of examiners from the Excellence in Missouri Foundation as a result of our most recent Missouri Quality Award application.

GVMH submitted its first Missouri Quality Award application in 1999 and we’ve continued to participate for the past 17 years.  Although the process involves the word “Award” the value is in the feedback we receive from our application and the value of the feedback is increased by a site visit.

The application we submit is 50 pages and is a response to the criteria for performance excellence based on the Malcolm Baldrige National Quality Award Criteria.  The feedback we receive as a result of the application and site visit will provide us actionable feedback to help us grow and improve as an organization.

While on-site, examiners will look at our approach, deployment, learning and integration for processes we use in the areas of leadership, strategic planning, customer focus, knowledge management, workforce focus, process improvement and results of our activities relative to our five pillars – people, service, quality, finance and growth.

Examiners will be meeting with hospital personnel to better understand the information we submitted in the application and examiners will be traveling throughout the organization in hopes of talking with as many staff as possible to validate that we do what we say we do.

We help people get better everyday, our participation in the Missouri Quality Award process provides us feedback to get better as an organization.  The better we are as an organization the better we can help those we serve.

I’m excited for the site visit and I hope you are as well.  If you have an opportunity to visit with one of the examiners tell your story with pride because at GVMH we have a lot to be proud of!

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The insurance marketplace; buyers and sellers needed


The Affordable Care Act better known as Obamacare, has a lot of moving parts.   One of the main aspects of Obamacare, insurance marketplaces, have hit a rough spot.  The law’s online marketplaces — where people were supposed to be able to easily shop for health insurance — have been suffering from double digit premium increases and defections by big name insurers.

Three years in, many of the established, and known, insurers say they are seeing losses from selling individual plans. Many of the nonprofit Blue Cross plans and other known insurers are having trouble. Insurance co-ops created by the law have mostly gone out of business and one of the biggest insurance providers, United Health has exited most states where it once offered individual plans.  In addition, Aetna has pulled out from 11 states.   The defections are adding up and it appears there is something of a herd mentality taking place and no one insurer wants to be the last one participating.

When the marketplaces were established the thought was competition amongst insurers hoping to sign people up for their plans would help to keep premiums low.  In addition to controlling cost, the marketplaces should also help to improve service.  In theory that’s what competition does, decrease cost and improve service but now fewer options exist and it’s estimated that 17% of people eligible for the market will have no choice of carrier next year.

Health insurance is a business and insurance companies want to stay in business which means they can’t operate at a loss.  One way to bring insurance providers back to the table is to increase the number of enrollees but they have to be the right types of enrollees.  Premiums will continue to grow if heavy users of health care continue to shop on the marketplace and cost control goes out the window.  Young, healthy people are the key to reducing costs in the marketplace.  Healthy people consume fewer health care resources so they help to offset the cost of insurance for everyone covered by a plan.  To date there are only half as many people as projected participating in the health insurance marketplace so enrollment has never grown to a critical mass.

There’s been talk about the government creating, and selling, an insurance product to compete with private insurers.  As you can imagine, this approach is controversial and probably won’t receive enough bipartisan support to work.  Tax incentives could be increased to help cover the cost of insurance for those who are shopping on the marketplace.  While incentives may encourage more participation, it doesn’t seem like incentives will reduce cost.  It’s kind of like moving money from one pocket to the other.

There’s no easy solution and there’s a lot of uncertainty in how to improve the market place.  One thing is certain, a marketplace only exists when both a buyer and a seller are present.  To date the health insurance marketplace doesn’t have enough buyers and there are fewer and fewer sellers.

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Aim for Excellence


Patients deserve and expect safe, high-quality, evidence-based care from their health care providers. This requires hospitals to have a continuous focus on improvement to ensure the quality and safety of the care delivery processes and the use of evidence-based practice.

In 2013 GVMH made the decision to eliminate Catheter Associated Urinary Tract Infections (CAUTI) in our organization.  To accomplish our goal we began a comprehensive, interdisciplinary quality and safety improvement project to reduce catheter-associated urinary tract infection (CAUTI) by 25% through implementation of evidence-based policies, processes, and protocols.

There were many reasons this project was given priority focus at our organization.  CAUTI was the most common healthcare-associated infections occurring within our patient population and considered to be reasonably preventable when appropriate, evidence-based strategies are in place, this project was deemed as one that could significantly improve patient outcomes and experience, as well as reduce the costs associated with care and treatment of patients who develop a CAUTI.

Research estimates that costs associated with CAUTI range from $911 to treat a symptomatic CAUTI (with a 1 day length of stay increase) up to $3,824 to treat a blood stream infection associated with an indwelling urinary catheter (with an average of 3 days length of stay increase).

Through hard work and diligence by nursing staff and providers, GVMH has gone more that 1,000 days without a CAUTI and we are being recognized as a leader in the state for our efforts.

On November 3, GVMH will be presented with the prestigious Aim for Excellence Award at the Missouri Hospital Association Annual Convention.  The award recognizes up to six hospitals across the state who have been successful at improving the patient experience, improving patient health and decreasing cost.  GVMH has been identified as a role model organization in reducing CAUTI’s.  More importantly, GVMH is being recognized for our efforts in the primary role of all health care providers – “first do no harm”.  Adopting processes to help our patients avoid preventable infections is more than just good care, it’s about saving lives and providing the best care.

GVMH is your hospital and that’s why we Aim for Excellence.


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CMS Star Rating


In late July the Centers for Medicare & Medicaid Services (CMS) released Overall Hospital Quality Star Ratings for all hospitals in the United States.  The Star Rating is designed to help individuals, their family members, and caregivers compare hospitals in an easily understandable way. Over the past decade, CMS has published information about the quality of care across the five different health care settings that most families encounter.  The new Star Data incorporates more measures and allows consumers to compare hospitals side by side which increases transparency.

The new Star Rating methodology takes 64 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars. The rating includes quality measures for routine care that the average individual receives, such as care received when being treated for heart attacks and pneumonia, to quality measures that focus on hospital-acquired infections, such as catheter-associated urinary tract infections.

The rating system has come under scrutiny because some hospitals contend that socioeconomic data does not factor in.  Patient’s who do not have ready access to healthcare services either because they do not have health coverage, or services are not available in their community, are at a disadvantage.  Health outcomes are impacted by a patient’s ability to access care.  The more access a patient has to care the more likely they are to receive timely treatment.

Only 2% of hospitals received a 5 Star Rating and roughly 20% received a 4 Star Rating.  GVMH received a 4 Star Rating and compares very favorably to hospitals in this region and across the country.  GVMH was above, or at, the national average for all measures.

GVMH’s 4 Star Rating fits with our Mission: To provide exceptional health and wellness services with friendliness and compassion.

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I’m back



The blog has been under “construction” the past few months.  It’s back now and promises to be better than ever.  By construction I mean, this blog has been neglected due to the recently opened, 93,000 square foot expansion at GVMH.

The expansion has been fully occupied.  The new Emergency Department is in service and the fast track process for patients who have less acute needs, like sore throats and ankle sprains, has been rolled out.  The purpose of the fast track is to get patients in and out of the Emergency Department in a more timely manner.  There is a special fast track waiting area inside the department and patients who don’t need a bed are never taken to a bed.

New surgery suites are in use.  We used to have four operating rooms and now we have six.  We have six of the largest, most technologically advanced surgery suites anywhere in the region.  The new operating rooms accommodate new and additional surgical procedures and quicker turnaround time between surgical cases.

The Imaging Department has a home in the expansion and now all of our Imaging Services (x-ray, CT, MRI, mammography, ultrasound, nuclear medicine and PET scan) are all in one place.  Patients needing multiple imaging services are now only steps away from the service they need as opposed to a floor away.

The Outpatient Treatment Center is up and running and we are able to host more specialty clinics like Oncology, Cardiology, Nephrology and Pulmonology.  Wound Care finally has dedicated space and is no longer borrowing space from other departments.  The infusion area now offers more privacy for patients and will accommodate 8 more patients than the previous area.

Cardiac Rehab offers patients the best view anywhere in the facility.  There is a walking track integrated into the floor and 8 additional pieces of equipment so patients no longer have to wait for a piece to free up.

The Outpatient Entrance provides easy access to many of our outpatient services and as construction continues over the next 18 months, the corridor coming off the outpatient lobby will provide convenient, easy access to all of our outpatient services.

The lobby itself is warm and friendly.  Our great volunteers greet patients when they enter, Registration is conveniently located just inside the entrance.  The artwork is beautiful and the Bistro provides great food and drink for the convenience of our patients and visitors.

Parking and services are all ground level and additional curb side parking just opened last week.  The entire outpatient expansion was created to improve access and convenience for our patients and visitors and there’s much more to come!


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Move in is quickly approaching


If all goes as planned we will be providing services to patients in new space in about a week.  The flurry of activity is currently at break neck pace and I for one won’t sleep well until the doors are opened to our community.  Here you can see the exterior logo sign being installed.


This is a picture of the new Emergency Department waiting area.  The new Emergency Department has a separate entrance and has 15 treatment bays as opposed to the 10 in the current Emergency Department.


This picture shows the corridor that connects the Outpatient Services Expansion to the main hospital.


Here’s a picture of the Imaging Department waiting area which is located adjacent to the main lobby.  If you’re familiar with the current Imaging waiting area you will note that this area provides for a lot more elbow room.


A little bit further into the Imaging Department you’ll find staff break and meeting rooms.


This picture shows one of the treatment rooms in the new Emergency Department.  The rooms are large and efficient and will provide for increased patient safety through better observation.


If you need a Starbucks fix, don’t forget the Bistro, located in the main lobby of the expansion, will proudly serve Starbucks coffees, teas, lattes and espresso….

It’s almost here!!!!

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