The end of fee for service will soon rank with death and taxes. Certain. As the countdown begins, how can hospitals start the migration to more accountable, high-quality and appropriate care and protect profits in 2013’s intensely competitive environment? Start right now, advises Banner Heart Hospital CMO Mark Starling, MD.

Mesa, Ariz.-based Banner Heart Hospital is the first accredited Heart Failure Institute in the state, going back to September 2009; it was seventh of about 70 hospital members across the nation to earn accreditation. Banner Health System also is one of only two accredited health systems nationwide, which includes four Banner facilities as Heart Failure Centers.

An innovator in care, Banner Health System also is one of the first accountable care organizations in the U.S.

The system has scrutinized the economics and quality of cardiovascular care, namely curbing heart failure and PCI readmissions. The results are impressive, with Banner Heart’s heart failure 30-day readmission rates running about 14 percent, with a low of 8 percent, according to Starling. Just a couple of years ago, those numbers were about 25 percent. Nationally, nearly one in four Medicare beneficiaries admitted to a hospital with a diagnosis of heart failure between 2005 and 2008 was readmitted within 30 days (Circ Cardiovasc Qual Outcomes 2009;2[5]:407-413). Heart failure incident rates also continue to rise in the U.S.

Results are top-notch in managing PCI too, both in terms of patient outcomes and driving down costs. Banner was the first hospital in its county to initiate a STEMI program and operates with door to balloon times of less than an hour.

“System-wide, cath lab and administrative teams meet regularly to look shrewdly at the number of stents utilized, types and costs of anticoagulants, appropriate patient selection and examine workflow and scheduling to push high volumes—always maintaining excellent quality and focus on patients,” Starling says. Banner Heart’s 30-day acute MI readmissions are down to about 12 percent from 18 to 20 percent, he adds, while mortality rates are very low.

To see similar results, "you need a plan, a dedicated team, dedicated cardiologists and great attention to detail to be sure each piece is carried out consistently for every patient at every facility every time,” he says.

Where to start

At Banner Heart, more effective patient management started with flow mapping, relationship diagrams and a management engineer who helped the health system refine process, Starling says. “Everything flowed to the ED and we saw readmission rates of 25 percent from there. That was too high. We also had to figure out a new plan as our whole model of care was wrong.”

So they changed tack, deploying a Rapid Evaluation Unit (REU) in the ED at Banner Baywood Medical Center, which is shared with Banner Heart, and a new patient management model. Now, patient management, at the heart hospital and other Banner sites, begins when a patient with chest pain enters the ED. This REU medical observation and evaluation unit bridges the gap between admitting a patient to the hospital for further treatment, and sending a patient home when a diagnosis may still be in question.  

In the cath lab

The Banner Cardiology Clinical Consensus Group continually redefines clinical practice. A PCI appropriateness checklist for cardiologists is its latest implementation. In the cath lab, a new safe procedure policy similar to surgical policies took efficiency up a notch. 

National and local coverage decisions are built into Banner’s PCI and cath procedures. “We make sure over and over that our providers are doing appropriate tests and procedures for appropriate indications,” Starling says. Guidelines and technology help physicians make treatment decisions during PCI. Fractional flow reserve (FFR) is one tool that helps clinicians decide which lesions to stent—those with an FFR lower than 0.80—or not. “FFR is most helpful in deciding when to stent occlusions in the range of 30 percent to 70 percent,” Starling says. “We have a lot more selectivity with FFR as it differentiates clearly which lesions impede vital flow. That is where we stent.”

The mix of stents has evolved a bit over the last few years, with Banner now using about 70 percent drug-eluting stents, down from about 90 percent. “We continually urge physicians to think about decisions such as using one longer stent vs. three shorter stents [when we only get paid for one],” he says. “We also look at anticoagulants, for best practices and costs.”

The Banner model

The objective of Banner Heart’s interdisciplinary heart failure model is driving quick decision-making. Admitted patients play a key role in their own care, learning how to weigh themselves and carrying out the task in the hospital—with the expectation it translates to home as well. “This is step one of patient empowerment,” Starling says. 

Throughout the Banner Heart system, patients move through hospitals, skilled nursing facilities (SNFs), rehabs and home care and get additional support such as nutrition, meal planning and exercise, always with a consistent message. The health system has standardized patient education and scripted messages to patients for consistency. Staff go over detailed clinical discharge instructions with patients, family members or friends who will help with care.

Upon discharge from Banner Heart, every patient has appointments to see a clinical pharmacist within 72 hours and a cardiologist within five to seven days or within 10 to 14 days if he or she takes part in a cardiac rehab program. “The physicians were stunned with the results in terms of the functional, mental and physical capability of patients,” Starling says. “And the whole process empowered patients to take care of themselves.”

The economics of care

The other essential piece for a health system to learn to adapt in a changing healthcare market is economics—and bundled payments. Banner Heart has put in place acute care episode bundling programs along with its managed care arm for heart failure and AMI. Led by Banner Heart, three Banner facilities applied for the Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement initiative for heart failure, an innovative model that includes financial and performance accountability for episodes of care. They also are working to bundle products for national and international corporation and payers, with Starling expecting they’ll be up and running by summer. “The end game is medical tourism,” he notes.

Bundled payment is the solution, Starling says and here’s why: “We will never have the density of procedures we do now and, thus, we have to plan by seeking to cover more lives. Rather than the 250,000 Banner Health Network currently covered lives, our goal as a network is a million or more, growing to 1.7 million by 2017. This will allow us to continue to provide high quality care that is bundled and low cost.”

Overall, Starling says data show Banner Heart is providing better care at lower cost. “All of our costs have declined quarter upon quarter in every heart failure and AMI DRG group…[But] we need to be clever. Reimbursement is going down, we know that. Plan for it, be creative, engage your medical staff in a unique way to be able to understand patients in a future environment. If you haven’t done that, start right now.”