Costs and Savings Examples - HHSC - DSRIP Program



Costs and Savings ExamplesIntroductionBelow are three examples illustrating different approaches to the Costs and Savings analysis. These examples are intended to help providers establish the scope of the Costs and Savings analysis as it relates to the Core Activity under review. Once the scope of the analysis is established, providers will gather costs associated with implementing and maintaining the intervention(s) associated with the Core Activity under analysis as well as healthcare costs for the target population pre and post intervention. For the forecasted analysis, healthcare costs post intervention is calculated using assumptions and trends for expected growth in healthcare expenditures for the target population absent the intervention. All of the examples outlined below are intended to be applicable to a retrospective or forecasted analysis, regardless of the verb tense used. Included at the end of this document is Attachment A, Costs and Savings Narrative Template, which can also be found as an attachment to the Costs and Savings guidance document.Example 1Core Activity: Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co‐morbidities, and/or utilizing acute and emergency care services.Description of Core Activity: This Core Activity seeks to identify the patient population that is at high risk of developing complications, co-morbidities, and/or utilizing acute and emergency care services for Diabetes and Heart Disease. The goal of this Core Activity is to properly manage these patient’s diseases by providing education to patients about self-management their disease, coordinating primary and specialty care for these patients, and educating primary and specialty providers on proper care for patients with these diseases by improving foot exams, eye exams, screening for high blood pressure and follow-up, appropriate statin therapy for high-risk Heart Disease patients, etc.Scope of Analysis: This Core Activity is broad in its scope, and the provider completing the analysis would like to only analyze this Core Activity for the Diabetes component.Quality Initiatives Associated with the Core Activity for the Diabetes Component: Providing education to patients regarding self-management of Diabetes by establishing and staffing a direct nurse line offering guidance to patients regarding DiabetesProviding education to patients regarding self-management of Diabetes by offering monthly meetings regarding living a healthy and active lifestyleTraining providers to offer self-management education to their Diabetes patients during primary and specialty care visitsCreating and providing educational handouts for Diabetes patientsIdentifying Diabetes patients and providing additional outreach to these patients by scheduling regular visits with primary or specialty care, and following-up with Diabetes patients after visits or discharge to ensure compliance with medication, provider care instructions, or follow-up instructionsTraining providers to properly treat Diabetes patients by administering proper foot exams, eye exams, regularly seeing Diabetes patients for preventative services, etc.Educating providers about the need to manage and control Diabetes and best practices for managing and controlling Diabetes.Purpose for Completing the Analysis: Provider wants to see if the cost of implementing and sustaining the Core Activity for Diabetes resulted in savings to the system by decreasing ED utilization and reducing preventable health care costs. Provider’s management would like to use the Costs and Savings analysis to see the benefits to the provider’s system only; therefore, provider will only use costs from their facilities, and the provider does not have contracted facilities. Provider is not seeking to establish an Alternative Payment Model with a Managed Care Organization but would like to see if the Diabetes interventions established during DSRIP are sustainable without DSRIP funding. Uncontrolled Diabetes is an issue for this provider’s region.Provider’s System Components: Provider has two outpatient clinics where primary and specialty care services are provided. Provider also has inpatient services and an Emergency Department.Target Population: All individuals with Type 1 or Type 2 Diabetes, regardless of payer type.Cost Data Needed for Tool: Healthcare costs associated with the Target Population pre and post interventions, program start-up costs for implementing all interventions associated with the Core Activity for the Diabetes component, and any costs to maintain these interventions. Cost data for this example could include the following:I.T. costs to modify the E.H.R. workflowSalary costs for additional staff for the direct nurse line, additional outreach, and scheduling assistance/care coordinationCosts associated with holding monthly meetings for Diabetes patients which could include cost to rent space for the meetings, costs to develop and print handouts, costs for meeting activities, costs of healthy refreshments, staff salary costs, etc.Supply costs and salary costs to create and provide educational materialsHealthcare costs for the target population pre and post interventionCosts of offering training/continuing education to providers regarding Diabetes Attachment A - Narrative: The narrative template contains questions meant to support and further analyze the results from the Costs and Savings tools. The narrative template contains specific questions, but these questions should be broad enough to allow the provider to tell their story. For this example, the provider has chosen not to include costs outside of their system, so provider will explain this in the narrative. For example, provider could explain in the narrative that pharmacy costs were not assessed as this would not be a cost to the provider performing the analysis. In this example for Diabetes, the target population could accrue more pharmacy costs post-intervention as patients are receiving more preventative care including medication to control their Diabetes therefore preventing unnecessary ED costs. Explaining the scope of the analysis in the narrative will help to explain the results from the tool, especially for provider’s wishing to only analyze internal costs. Provider will also explain in the narrative how the provider is only analyzing a component of the chosen Core Activity.Example 2Core Activity: Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross‐continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.Description of Core Activity: Provider will expand care transition and discharge planning to better support individuals that are at a higher risk for admissions, readmissions, complications, and ED visits by staffing a care transition team to provide transition and discharge planning for these patients with the goal of improving resource utilization within and outside the organization. This Core Activity will focus on overall risk identification of patients with a concentration on mediation of those risks prior to discharge and improvement of post-discharge follow-up planning. This Core Activity will include stratifying patients according to risk to different follow-up intervention models established as part of this Core Activity.Scope of Analysis: The provider completing the analysis would like to analyze the entire Core Activity.Quality Initiatives Associated with the Core Activity:Establishing screening policies to determine how patients will be stratified by risk and implementing different follow-up intervention modelsCreating a care transition team by hiring additional staff to ensure patients identified as high risk receive the appropriate level of care and follow-up/transition servicesProviding educational materials for medication management and follow-up care instructions to patients or their care givers during their appointments or pre-dischargeEnsuring patients or care givers are aware of any follow-up care instructions or medication instructions by modifying the E.H.R. workflowProviding additional education and outreach to patients on managing their diseases via a nurse help line staffed by the care transition teamEnsuring patients seen in the ER are receiving follow-up with primary care or specialty by scheduling appointments for patients pre-discharge or soon after dischargeIdentify patients with socioeconomic issues that need community resources, and the care transition team will provide additional outreach to these patientsEnsuring better documentation of patient medication by modifying the E.H.R. workflow to prompt providersEnsuring patients are transferred to home or a different health care facility with specific elements from the medical record by modifying the E.H.R. workflow to prompt providersEnsuring current medications are up-to-date in the medical record by modifying the E.H.R. workflow to prompt providersPurpose for Completing the Analysis: Provider wants to see if the cost of implementing and sustaining the Core Activity resulted in savings to the system by decreasing ED utilization and reducing preventable health care costs. Provider’s management would like to use the Costs and Savings analysis to see the benefits to the provider’s system and other providers in the region; therefore, provider will use costs from their facilities, their contracted facilities, and other facilities in the area. Provider would like to use the Costs and Savings analysis to help establish an Alternative Payment Model with a Managed Care Organization. Provider will attempt to quantify costs from outside their entity through data sharing agreements with neighboring providers or through available literature and research.Provider’s System Components: Provider has multiple outpatient clinics where primary and specialty care services are provided. Provider also has three hospitals providing inpatient care and three Emergency Departments.Target Population: All patients, regardless of payer type, identified as high risk for admissions, readmissions, complications, and ED visits as identified by the care transition team. Cost Data Needed for Tool: Healthcare costs associated with the Target Population pre and post interventions, program start-up costs for implementing all interventions associated with the Core Activity, and any costs to maintain these interventions. Cost data for this example could include the following:I.T. costs to modify the E.H.R. workflowSalary costs for additional staff for the care transition teamSupply costs for providing educational materialsCosts associated with developing and maintaining new screening policies, procedures, follow-up intervention models, etc.Healthcare costs for the target population pre and post interventionAttachment A - Narrative: The narrative template contains questions meant to support and further analyze the results from the Costs and Savings tools. The narrative template contains specific questions, but these questions should be broad enough to allow the provider to tell their story. For this example, provider will explain in the narrative if the costs are attributed to the provider or to some other entity outside of provider’s system. Provider will also include in their response to the methods and assumptions narrative question how the provider arrived at the cost data from outside their entity.Example 3Core Activity: Utilization of telehealth/telemedicine in delivering behavioral servicesDescription of Core Activity: Provider is a CMHC that utilizes telemedicine as its primary source of delivering behavioral health services to its catchment area. The expansion of this Core Activity builds on a previous DSRIP project and will increase physician availability across a rural area, decrease appointment wait times, and decrease inappropriate law enforcement incarcerations and emergency room admissions. In order to accomplish this Core Activity, provider will hire additional clinical staff and put policies/checklists in place to ensure regular screening for behavioral health risk factors during appointments. Scope of Analysis: The provider completing the analysis would like to analyze the entire Core Activity. This Core Activity is tied to measures M1-146, M1-160, M1-305, and M1-319, and the provider feels that the initiatives related to this Core Activity overlap and the scope of the Core Activity is narrow enough for analysis.Quality Initiatives Associated with the Core Activity: Provide rapid follow-up to patients after hospitalization for mental health issues by hiring additional clinical staff to increase appointment availabilityIncrease physician availability and decrease appointment wait times for mental health services by hiring additional clinical staffModify visit check lists and procedures to ensure patients are receiving depression and suicide screening and proper follow-up, if neededExpand provider’s telemedicine capabilitiesEducating and training providers about best practices for treating mental health issues to avoid hospitalizationTraining providers on how to use telemedicine technologyPurpose for Completing the Analysis: Provider wants to see if the cost of expanding and sustaining this Core Activity resulted in savings to the healthcare system by decreasing ED utilization, reducing preventable healthcare costs, and preventing inappropriate law enforcement incarcerations. Provider’s management would like to use the Costs and Savings analysis to see the benefits to the healthcare system to secure funding; therefore, provider will use costs from their facility and literature/statistics or data sharing agreements for incarceration and ED costs. Provider plans to collect cost and ED utilization information for the patients benefiting from the telemedicine services from the hospitals and/or literature/statistics and establishing access to incarceration data from law enforcement entities and/or literature/statistics. Provider is not seeking to establish an Alternative Payment Model with a Managed Care Organization but would like to see if the interventions established during DSRIP are sustainable without DSRIP funding or if the demonstrated quality improvements and associated savings to the health care system made during DSRIP could lead to additional sources of funding. Provider’s System Components: Provider has home-based services and services offered in the clinic/office. Target Population: Any customers seen at the CMHC using telemedicine.Cost Data Needed for Tool: Healthcare costs associated with the Target Population pre and post interventions, program start-up costs for implementing all interventions associated with the Core Activity, and any costs to maintain these interventions. Cost data for this example could include the following:I.T. costs to expand and maintain telemedicine capabilitiesCosts to train staff on using telemedicine technologyContinuing education costs for provider on best practices for treating mental health issues to avoid hospitalizationSalary costs to hire additional clinical staffHealthcare costs for the target population pre and post intervention, including Emergency Department costs from hospitals and/or literature/statisticsDaily incarceration costs, average length of stay for incarceration, probability of being incarcerated without proper mental health services or actual changes in incarceration for mental health issues post intervention, etc. from literature/statistics or from law enforcement entitiesCosts to modify visit check lists and procedures Attachment A - Narrative: The narrative template contains questions meant to support and further analyze the results from the Costs and Savings tools. The narrative template contains specific questions, but these questions should be broad enough to allow the provider to tell their story. For this example, provider will include an explanation in the methods and assumptions narrative question regarding how provider arrived at the incarceration cost data from literature/statistics or from law enforcement entities. For this example, provider might also explain in depth the other benefits from these interventions such as benefits to society and the patient’s quality of life.Attachment A: Costs and Savings NarrativeTemplateAttachment A OverviewPerforming Providers with total valuation of one million dollars or more per DY must respond to the questions in this attachment as part of the Cost and Savings analysis. Performing Providers should complete all questions in this attachment and submit the attachment in the DSRIP Online Reporting System along with the completed Costs and Savings tool. Please see the Costs and Savings Recommended and Alternative Tools section of this document for additional information on acceptable tools for use in the Costs and Savings analysis.Attachment A QuestionsIn the space provided below, please describe the initiative being analyzed in the Costs and Savings analysis. This description, at a minimum, should describe the initiative itself, what the initiative seeks to accomplish, and the population being targeted or benefiting from the initiative.Performing Provider Response:In the space provided below, please summarize the results of the Costs and Savings analysis. This description, at a minimum, should include whether the Costs and Savings analysis indicated a savings/benefit or a loss from the initiative being examined. In this description, please also indicate if the savings/benefits or losses were attributed to the Performing Provider or to some other entity outside of Performing Provider’s system, including the state or Medicaid.Performing Provider Response:In the space provided below, please explain the constraints in affecting 100% of the target population with the initiative. The target population would be the patient population that Performing Provider is seeking to affect with the initiative (i.e., patients with diabetes). For example, limited resources or space, additional outreach/education needed, patient refusal to participate, lack of patient contact information, lack of interest, limited enrollment, etc. could all constrain a Performing Provider’s ability to affect 100% of the target population. If a Performing Provider believes the initiative being examined in the Costs and Savings analysis reached the maximum number of patients, then please explain why. The Performing Provider’s response should also indicate how an increase in enrollment in the initiative or an increase in the number or people affected by the initiative would affect the Costs and Savings analysis (e.g., would an increase in enrollment give the Performing Provider a better ROI?).Performing Provider Response:In the space provided below, please describe how the intervention being examined in the Costs and Savings analysis impacts different stakeholders. The impact must be directly tied to the intervention being examined in the Costs and Savings analysis. The Performing Provider’s response must include how Medicaid and at least two other stakeholders listed below are impacted by the initiative, and the response should indicate how the impact is tied to the intervention being examined in the Costs and Savings analysis. Please note that the narrative response does not need to include actual or estimated data.Medicaid (required)Other third-party payersState or local governments (e.g., incarceration/recidivism, etc.)Society (e.g., loss of productivity, substance abuse leading to school drop-out or incarceration, homelessness, environment, etc.)Employer of the patientPatientOther providersOther stakeholders (Performing Providers must indicate or describe the “other” stakeholder in their response to this question)Performing Provider Response:In the space provided below, please describe any benefits to the Performing Provider’s organization due to the intervention that may not be captured in the Costs and Savings analysis. These benefits could be an increased recognition for quality, enhanced market share, employee satisfaction/retention, enhanced accreditation, fulfillment of mandated requirements (such as requirements to participate in Medicaid), etc.Performing Provider Response:In the space provided below, please describe how the initiative being examined in the Costs and Savings analysis is directly related to a current Category A Core Activity.Performing Provider Response:In the space provided below, please describe the data sources used to complete the Costs and Savings analysis, including internal data sources and data sources from outside of the Performing Provider’s system.Performing Provider Response:Please describe the assumptions made and the methodology used to complete the Costs and Savings analysis.Performing Provider Response: ................
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