American College of Cardiology

SMARTCare Delivery

Smarter Management and Resource Use for
Today’s Complex Cardiac Care Delivery

Executive Summary

Smarter Management and Resource Use for
Today's Complex Cardiac Care Delivery
Executive Summary
June 2010
Updated: June 29, 2011

SMARTCare proposes to address documented clinical, resource use and cost variation in the diagnosis and treatment of stable ischemic heart disease (SIHD) by:

1. Utilizing tools, at point of care, to encourage appropriate patient selection, through

a. Use of evidence based guidelines and appropriate use criteria
b. Predictive modeling for the likelihood of benefit or complication for a particular intervention
c. Improved patient understanding of care through an individualized, well documented, shared decision making process

2. Monitoring quality and performance metrics displayed through system and provider specific dashboards with relevant standard cost and outcome data

3. Utilizing an episode-based payment system, adjusted for quality that requires shared risk among multiple stakeholders

Implementation will be accomplished over a two year period using an experiential learning model. Adjustments will be made throughout the project by individual sites within the general construct of the project. Rather than a randomized, double blind controlled experiment, improvements in broad quality metrics along with an evaluation of value as assessed by each project stakeholder will be used to gauge success of this project. A strict research design was judged to likely inhibit the actual changes being encouraged by this project and could delay deployment. Historical trends and non-participating sites will be used for comparison purposes when determining impact of this project.

The project will leverage the claims database developed by WHIO(1) along with the clinical registries and quality improvement expertise of ACCF(2) to engage physicians and patients toward proper and effective management and resource use over time. Implementation and refinement of project measures will be built upon knowledge accumulated through the use of tool sets provided by the project. For example, dashboard display and quality adjustors will not be implemented until the end of the first three months of the project, so as to allow ample time for each component of the dashboard to be populated based data collected during tool use. At the point that stakeholders agree that the data is mature and represents an accurate portrayal of care, system performance will be released to the public utilizing an updated WCHQ patient portal. Individual provider results, where appropriate may later be released through this portal as well.

The payment model will involve three components: 1) fixed per case payments for professional, outpatient facility fees and care management, 2) bundled procedure payment for PCI and CABG to include device, inpatient and ancillary costs per case (risk adjusted), and 3) a quality adjuster across the episode to reward metric achievement and reduce the likelihood of unintended consequences.

It is believed, integration of these methods will result in less variation in care and better understanding of the factors resulting in any noted variation. Likewise, providers will be better equipped to adjust care based on scientific evidence, individualized to the patient, rather than crude metrics such as length of stay or total cost (see Figure 1. in SMARTCare Delivery Proposal Overview).

1. Wisconsin Health Information Organization
2. American College of Cardiology Foundation

Project Background/Details

SMARTCare Delivery
Smarter Management and Resource Use for
Today's Complex Cardiac Care Delivery
Project Background and Details

Background
Geographic and institutional variation has been documented for clinical, resource use, and cost across a wide spectrum of medical care. In fact, many states have begun to track some of this variation in near real time by developing multi-payer claims databases.(3) In the state of Wisconsin, WHIO has developed a multi-payer database capable of displaying resource cost variation for a wide variety of conditions. Providers participating in the review of the WHIO data acknowledge variation. Yet the lack of clinical context for the WHIO data precludes clinicians from understanding potential areas for meaningful clinical change. Without such clinical information, any action might be focused on efficiencies aimed at driving down total cost or crude metrics such as length of stay. While important, these metrics may or may not reflect clinical quality and could have unintended consequences of higher long term cost and lower true clinical quality. Fortunately, some areas of medicine already have rich sources of clinical data along with process improvement programs that could help provide context for WHIO data.

Within cardiology, the type of diagnostic and treatment options selected for patients with probable and known stable ischemic heart disease (SIHD) often appears to differ based primarily on location and physician. This is especially true when only cost of resource use is considered. In this clinical setting, diagnostic options include basic risk factor calculators, treadmill testing, non-invasive and invasive imaging. Treatment options include medical therapy, percutaneous coronary interventions (PCI), and coronary artery bypass graft (CABG) surgery. Complications arising from the procedures as well as the election not to perform a procedure can have a significant impact on the patient’s course of disease, resource use, and total cost. The variation and complications may reflect geographic or physician preferences and do not always align with patient preferences. Finally, payment for these procedures is currently aligned based on volume rather than quality.

Claims and clinical data collection, appropriately benchmarked and presented in an integrated dashboard could provide better insight into these variations. Tools presently exist which focus on improving physician and patient selection of diagnostic procedures, predict individualized procedure success or complication, and guide the patient and clinician through an understandable and well documented shared decision making (SDM) process. Integration of these tools, at critical points in the patient care process, may facilitate decisions that are more evidence based and patient centered (see Figure 2. Patient Clinical Workflow for Stable Ischemic Heart Disease). Payment reforms that focus on rewarding physician work based on cognitive skills, patient interaction, adherence to practice guidelines, and outcomes rather than volume may support the adoption and maintenance of such tools which engage physicians and patients around appropriate and patient centered procedure selection.

Figure 2: Patient Clinical Workflow for Stable Ischemic Heart Disease

3.http://apcdcouncil.org/state/map

SMARTCare Delivery Model Overview

Overview of SMARTCare Delivery Model
The WI Chapter of ACC and National ACCF, in conjunction with the WI Medical Society (The Society) propose the SMARTCare project as a potential solution for reducing geographic and physician variation while ensuring patient centered care. The project’s toolsets, metrics, and the necessary dashboard development will be rolled out in sequence building upon each other.

1. Four to six diverse practice sites, including large/small urban, and rural population centers with representative academic, community, multi-specialty, integrated hospital practice models, will be identified prior to initiation. All centers will be equipped with the necessary tools to be used at the point of care:

a. Non-invasive imaging decision support at the point of care (FOCUS)
b. Shared decision making (SDM) for ischemic heart disease treatment (medical therapy/PCI/CABG) and patient portal for information (SharedCare)
c. Invasive imaging and therapeutic option decision support at the point of care (PRISM)

2. Implementation of episode of care based payment system to align incentives and behaviors toward improved value. Payment would include episode based payment for both professional and outpatient facility components for initial diagnosis and treatment of stable ischemic heart disease and a bundled payment add-on for patients who select PCI or CABG (includes device, inpatient facility and ancillary services but not professional and outpatient services related to the procedure as these are accounted for proportionally in the main episode payment).

3. Linking of EHR systems with ambulatory cardiac care registry

4. Establish registry and WHIO data feeds into business intelligence software

5. Use of an integrated data dashboard of clinical and claims data to monitor variation and provide a means for continuous quality improvement

a. Use of ambulatory registry (PINNACLE) to monitor secondary prevention
b. Use of procedure registry (CathPCI and STS) to monitor procedure success and complication rates
c. Use of all claims dataset (WHIO) to monitor readmission rates and longterm resource cost utilization

6. Implementation of payment adjustment for attainment of quality metrics as measured in the dashboard

SMARTCare will leverage the capabilities of all stakeholders including the national and state chapter of American College of Cardiology, Wisconsin Medical Society, hospitals, health plans, employers, public payers, patients and physicians and their clinical teams. Each stakeholder will share in the financial risk resulting from this payment model. The project is proposed to be implemented and evaluated during an initial two year commitment by all stakeholders. The project is proposed to commence January 2012.

SMARTCare Delivery Proposal Overview

Figure 1: Overview of SMARTCare Delivery Proposal

Project Components

Project Components (Intervention)

Tools for Appropriate Patient Selection

1) Imaging Clinical Decision Support and Quality Improvement
The project would implement a performance-based cardiovascular diagnostic imaging utilization and optimization product. Built upon the core competencies of the American College of Cardiology, FOCUS emphasizes appropriate patient selection through:

1. Physician developed Appropriate Use Criteria
2. Point of order clinical decision support
3. Structured performance improvement activities

The product concentrates on patterns of appropriate use rather than individual cases to educate clinicians on appropriate diagnostic protocols for specific patient populations. The approach does not include denials and allows physicians to focus their improvement efforts on better understanding of the types of patients who do and do not benefit from imaging. Published studies and articles on use of such systems in Boston, Minnesota, and Washington State demonstrate significant impacts on appropriate use of imaging and trends in imaging utilization. A pilot run by ACC and UnitedHealthcare documented a large opportunity for improvement with on average 15% of nuclear cardiology tests not meeting criteria.

2) Shared Decision Making
The project will increase engagement of patients with suspected SIHD in care decisions through use of a web-based tools which provide patient specific rates for procedural success and complications. Use of the tools would be mandatory prior to a therapeutic invasive procedure.

Patient Shared Decision Making (SDM)

o Targets patients with probable SIHD as demonstrated by positive non-invasive tests or symptoms which may need invasive catheterization and possible treatment
o Activates distribution of SDM tools to patient at the time the pre-procedure office visit is scheduled
o Provides dedicated time for the patient to engage in SDM with their family, physician and his or her clinical staff.
o Facilitates a common language, knowledge base, and trust among the patient, family, caregiver, primary care doctor, and the cardiologist.

Patient Specific Procedure Risk Assessment

o Targets patients who may need invasive treatment
o Activates distribution of tools to clinician at the time the pre-procedure office visit is scheduled
o Provides patient specific risk assessment and clinician decision support prior to the procedure in order to tailor utilization of ancillary services which optimize procedure success while minimizing resource use necessary to achieve that success

Patient Engagement Beyond Shared Decision Making

o Assists patients not only in making treatment decisions, but also in their implementation through access to the patient information portal
o Provides patients with access to reliable source for patient clinical information
o Improves patient confidence in their decision and compliance with care required by their treatment choice.

Payment Model

Payment Model
Episode based payment models have been widely discussed as potential ways to encourage efficient use of resources across a set of health care providers. Some well known episode payment models are PROMETHEUS and bundled payment initiatives for procedures. Advantages of these payment models include maintaining a volume based payment with expected quality outcome while allowing more flexibility in the type of services delivered within the episode. These features discourage underuse, allow reallocation of effort to more poorly reimbursed cognitive services, and create incentives to reduce physician variability. However, traditional episode based payments are difficult to forecast accurately in ways that do not require substantial reserves by participating providers offering warrantee.

This project proposes to maintain the strengths of an episode of care payment while managing its risks and potential unintended consequences by breaking the episode payment for each case into three components:

1. Fixed professional, outpatient facility fees, and care management per case
2. Bundled procedure payment for PCI to include device, inpatient facility and ancillary costs per case and will be managed with tools for appropriate patient selection and risk adjusted based on NCDR
3. Quality adjustment factor per case to reward clinical outcomes, appropriate use, and secondary prevention

Each stakeholder will share in the financial risk resulting from this payment model. The model attempts to leverage the professional clinician and outpatient services payments which represent 32% of the costs of a typical stenting episode (see Figure 3. Percentage of Costs of Ischemic Heart Disease with Stenting). These resources will be used in ways that can optimize diagnosis, the choice of the treatment (based on appropriate use and patient preferences), and care management while measuring the achievement of clinical benchmarks. By doing so, the other 78% of the costs of a typical stenting episode will be optimized and in some cases avoided all together.

Figure 3. Percentage of Costs of Ischemic Heart Disease with Stenting (All Severity Levels)

Hospitals and physicians will be required to model their average cost per episode for professional services, outpatient facility fees and care management. Included in the fixed episode payment will be care management costs including all data, infrastructure, staffing, equipment purchasing and depreciation, administrative overhead, quality improvement tools (including imaging decision support, shared decision making, predictive models and registry services) and contributions to hospital reserves. The professional service fee will cover all clinician payments across the episode (including invasive procedures) and will require allocation to several providers. A primary care physician referral or cardiologist visit for initial diagnosis and treatment of potential stable ischemic heart disease will mark the start of the episode. Hospital systems will be expected to develop referral protocols that require primary care physicians to refer patients suspected of having stable ischemic heart disease to a cardiologist for evaluation. The referral will mark the start of the episode and ensure a cardiologist can properly perform risk assessment of the patient and triage to appropriate diagnostic and treatment services. The referral protocol also will allow for effective use of the range of appropriate use tools and initiation of primary and secondary prevention. The primary care physician may continue to manage portions of the episode related to aspects of primary and secondary prevention after initial assessment and initiation of any necessary treatment. The episode will extend through one year, rule out of CV disease, or an acute CV event, whichever is shorter.

Health plans and employers will be required to model the average inpatient procedure, device usage and ancillary costs across their population. Choices concerning utilization of services will be driven by tools designed to foster appropriate patient selection and alignment with patient values and may vary over time and among institutions based on shifts in patient mix and severity. Based on prior studies, this approach to selection of procedures should result in lower usage and slower growth over time. Devices and ancillary services costs also will be fixed and equal across pilot sites. NCDR risk adjustment will be used to modify the payment bundle to account for patient severity and complexity.

The quality adjustment factor will be indexed to provide both payment incentives and penalties based on performance. All stakeholders will share in the risk for these payments. Hospitals and physicians will need to monitor their performance for appropriate patient selection, outcomes, and quality measures. Health plans and employers will be required to model these payments to account for potential rewards such quality could deliver over time. Factors to be measured include outcomes (mortality, avoidance of complications, quality of life, quality measures, and rates of readmission), appropriate use and patient complexity/risk. Through proper selection, relative weight, and use of the quality metrics and quality payment adjustment, this project can encourage optimal care and appropriate resource use.

Stakeholder/Partner Investment/Return

SMARTCare Delivery
Smarter Management and Resource Use for
Today's Complex Cardiac Care Delivery
Requested Commitment and
Potential Partner Investment/Return

All Stakeholders:
Investment of seed funding for project development is needed in the amount of $50,000 each and potentially matched by the Centers for Medicare and Medicaid Innovation Center (CMMI). These funds will be used to support initial project implementation while payment changes from CMS and private payers/employers will support ongoing implementation.

The Chapter (WI-ACC):
Commitment: The Chapter will provide leadership for the state on clinical quality metrics, as well as tools and data to empower physicians and their patient. At the same time, the Chapter will assure clinicians are provided accurate and actionable assessment and evaluation of the care they deliver.

National ACC:
Commitment: The national ACC will engage stakeholders in the first comprehensive, integrated use of registry data and QI tools while documenting the incremental value such resources can provide clinically and financially to the care of patients.

The WI Medical Society:
Commitment: The Medical Society will convene stakeholders to demonstrate ways to integrate clinical and cost data and leverage clinical tools to affect change while engaging patients.

Health Plans
Requested commitment: This project seeks to engage health plans (public and private) to endorse empowering physicians to use tools of appropriate patient selection and a value-based dashboard by supporting a three part episode of care payment reform concept. In return, health plans and their members will gain access to additional tools and data to help them better understand and manage care for this patient population. The project requires shared risk and an understanding of the potential for short and long term savings from optimizing patient selection and better understanding the potential associations between clinical variation and resource use variation.

Employers
Requested commitment: This project seeks support of employers to endorse empowering physicians to use tools of appropriate patient selection and a value-based dashboard by supporting the episode of care payment reform concept presented earlier. In return, employers and their employees will gain access to additional tools and data to help them better understand and manage care for this patient population. The project requires shared risk and an understanding of the potential for short and long term savings from optimizing patient selection and better understanding the potential associations between clinical variation and resource use variation.

Hospitals
Requested commitment: The project seeks to engage hospital system to empower physicians to use tools of appropriate patient selection and a value-based dashboard. This project will require systems to commit to purchasing and implementing the tools used by the project, provide physicians governance opportunities within the system related to the project, potentially reallocate clinical resources and distribute episode-based payments among physicians not based on procedure but rather based on episode case volume. Hospital systems will also need to identify a project team and lead, quality champion, hospital champion, and implementation infrastructure.

Patients
Requested commitment: The project seeks patient groups to support engagement of patients in understanding their risk and communicating their preferences to their physician. Patient groups also will support the concept of physicians being paid per episode to manage their diagnosis and treatment rather than by procedure or service provided to individual patients. If this approach is deemed not only acceptable but valuable by patient groups, it is hoped that these groups will disseminate their experience, participate in refinement of the approach, and advocate for its adoption outside this project.

Governance

Governance

Management Controls and Mechanism for Change to Project Structure or Goals
Oversight and adjustment to methods of assessment, compensation, and commitments for this project agreement will be directed by a steering body comprised of a representative from each segment of stakeholders. Equal representation of each stakeholder segment or grouping is designed to allow equal influence or ability to change the course of this project.

Figure 4. SMARTCare Delivery Stakeholders

Meetings to review progress will be convened and moderated by the state medical society once a quarter with proposed changes to the overall project construct to occur no more frequent than once a year. At least three months of notice of change will be provided so as to allow ample analysis of and planning for the impact any patient, clinician, healthcare system, or other stakeholder will incur due to that change.

Day to day clinical and financial project management will be overseen by a project lead from WI ACC Chapter, ACC National, and State Medical Society and undertaken in coordination with project leads from each hospital system. Weekly meetings of this project management team will occur during the duration of the project.

WI ACC Chapter will appoint a physician member to serve as the overall lead for the project and serve as the Chair of both the steering group and project management team.

Data Reporting/Benchmarking

Data Reporting/Benchmarking

Ambulatory Cardiac Care Registry (PINNACLE)
The PINNACLE Registry is part of the ACC’s PINNACLE Network, the first-ever registry-based cardiovascular network to link ambulatory cardiology practices to each other and to the ACC’s NCDR. The registry provides a centralized system for participants to promote practice innovation and achieve clinical excellence. Participation offers many advantages, including:

• Easy-to-interpret quarterly benchmark reports that validate the quality care provided and pinpoint opportunities for improvement
• Access to relevant data focusing on coronary artery disease and hypertension
• Minimal data collection that delivers maximum clinical value
• Multiple seamless methods of data submission fitting any workflow

The PINNACLE Registry metrics are endorsed by the National Quality Forum (NQF), the Physician Consortium for Performance Improvement (PCPI), the Physician Quality Reporting Initiative (PQRI), and the American College of Cardiology and the American Heart Association.

CathPCI Procedure Registry
The NCDR® is the most comprehensive, outcomes-based quality improvement program in the United States, encompassing both hospital-based registries and a practice-based program. As a trusted, patient-centered resource, the NCDR is uniquely positioned to help participating facilities and medical professionals identify and close gaps in quality of care, reduce wasteful and inefficient care variations, and implement effective, continuous quality improvement processes. The NCDR CathPCI Registry includes a comprehensive training and educational program to addresses the educational needs of NCDR registry participants. In addition, ACCF offers on-line resources such as Registry Companion and Interpretation Guides, data collection tools and aids, and other supportive documents through the NCDR website (www.ncdr.com). Features of CathPCI Registry include:

• Risk-adjusted, quarterly benchmark reports that compare your institution’s performance with that of volume-based peer groups and the national experience
• Standardized, evidence-based data elements and definitions
• A complimentary online data collection tool; or a variety of certified third-party vendor software options
• A wide range of other quality improvement tools to advance QI initiatives within participating facilities
• Intracoronary device utilization, adverse event rates, and adherence to Appropriate use criteria for coronary revascularization
• Compliance with ACC/AHA Clinical Guidelines recommendations, and more

In addition to the automatic built-in data entry checks and the certification program, NCDR assesses the overall integrity and completeness of a participant’s data submission and provides feedback to the participants via a Data Quality Report (DQR). The DQR ensures well-formed data and a statistically significant submission by providing the participant with analysis of the completeness of their data submission based on established thresholds or NCDR minimum standards. This type of report is used by the participant to help prioritize data cleaning efforts and to assess the necessity for re-submission.

All Claims Database (WHIO Data)
The Wisconsin Health Information Organization (WHIO) has created a centralized administrative claims data repository, to date representing approximately 3.7 of 5.6 million Wisconsin patient lives across twenty-seven months of rolling care. This data characterizes approximately $29.9 billion in, “standardized cost (4).” This repository is the largest of its kind within the United States and contains more than 80% of commercial claims, 20% of Medicare claims (Medicare Advantage), and all Medicaid beneficiaries within Wisconsin. As a founding member of WHIO, the Society has equal access to the repository and stores raw data on its own server. Features of this Data Repository include:

• Longitudinal patient resource use independent of system through which it was provided
• Standardized cost data, allowing comparison of total and average cost of services provided, independent of factors related to location
• Range of analytical tools (Impact Intelligence®) based on facility and episodes of treatment

4. InGenix convention [consider white paper reference]

Quality Improvement Monitoring Tools

Tools for Monitoring Continuous Quality Improvement

Clinical Dashboard
For the clinician and hospital systems, it will be crucial to understand the effects interventions or changes in the approach to and the delivery of care have on outcomes and cost. ACC and the Society will develop on demand display of the most current data which identifies individual or system performance in key metrics and standard cost of utilized resources. These displays or dashboards will list the best and worst areas of performance and allow further, more specific investigation through additional intelligence tools. As part of this project, each provider will be identifiable and will be required to develop and implement an individual quality improvement plan. Each system will likewise be required to develop and implement a system quality improvement plan of their choice. The area of focus does not need to be uniform across all participants, so as to allow maximization of efforts around the greatest benefit for each. As such dashboards do not presently exist, the period prior to implementation and during the ramp up of the project will be used to develop and test the dashboards.

As dashboard displays will be tailored to specific individuals or systems, those metrics and displays will not be made available to the public. However, overall system performance metrics may be released through the WHIO patient portal at the time when all stakeholders agree the derived data is accurate, properly risk adjusted and meaningful to the patient. Non-clinician/system stakeholders will have access to system dashboard views. Additional views may be created at the request of stakeholders after review by the project governing body. System or practice performance may be used for selection and contracting. Individual practitioners will need to grant permission for non-clinician/system stakeholders in order to create a profile of that provider.

Additional Quality Recognition
A number of the tools used would provide mechanisms for clinicians and hospitals to fulfill accreditation and certification requirements. The imaging decision support tool includes quality improvement components that are certified for physician Maintenance of Certification Part IV credit and can fulfill laboratory accreditation requirements. Other data may be used by physicians to apply for self-directed Maintenance of Certification Part IV credit. Furthermore, a number of the data collection activities and tools may support future Meaningful Use requirements for electronic information.

Site Recruitment
WI-ACC and The Society would jointly recruit practices to include at least one of the following characteristics, and the pilot cohort to contain representatives of each:

• Academic
• Hospital owned
• Urban service
• Rural service

Description of Hospital Systems and Environment
Wisconsin has a long history of integrated care delivery systems. More recently, cardiology practices have become further integrated with hospital systems as practices have been purchased by hospital systems. As a result, cardiologists, primary care physicians and hospitals are now a part of a single legal entity and physicians are employees of the hospital systems. This legal structure reduces the hurdles to implementing the payment and referral protocols as have been proposed in this document. Payment and referral protocols can be established quickly to support use of the data and tools proposed for this project. Physician contracts may need to be amended to recognize the work involved in this new care management pathway and address changes introduced by bundled payments rather than volume-based RVU payments. However, overall Wisconsin offers a strong laboratory and learning environment that can fast track understanding of how such a care management model might work. Lessons learned could then be translated to other regions where care is less integrated by altering health plan contracts in ways that would support the changes implemented in this project.

Availability of Resources and Data Access
Wisconsin is uniquely positioned to utilize clinical and claims data given the legal agreements already in place within the state. WHIO already has data exchange agreements in place and the ACCF has existing contracts to provide registry data. The collaboration of all stakeholders in the state will allow the project to secure initial seed funding and allow hospital systems to transition to the proposed new payment model. The integrated nature of the hospital systems and physician practices will allow resources to be devoted to the use of the tools and data generated by the project.

Quality Assurance/Auditing
Each project component has a data quality assurance and auditing mechanism built into its contracts and procedures. These review processes will maintain a high standard for the data and information used in the project. For example, the NCDR has a data validation tool that examines submissions to the registry for out of range and inconsistent data. NCDR also has an audit program that examines 10% of the facilities submitting data annually.

Clinical Performance Results
The data dashboard will be used to review clinical performance results across the various metrics available from the registries. The metrics will include appropriate use, procedure outcomes and complications, and stable ischemic heart disease process measures and secondary prevention control. See Appendix A.

An additional list of metrics will be reviewed for potential integration into the dashboard that may be calculated based on the data fields collected in the clinical registries and claims database. These metrics may include both clinical outcomes and resource tracking that help physicians better understand their care delivery. In addition, a composite measure will be developed based on a Delphi process conducted among the stakeholders to identify the key metrics and the weighting that should be used to summarize performance over time.

Project Performance Tracking (operational and financial)
The governing steering committee will meet quarterly to review operation and financial performance of the project. These reports will be prepared jointly by stakeholders to report the implementation and impact of the project on their operations. The data dashboard will be utilized to track overall performance.

Anticipated Issues and Proposed Resolutions

Anticipated Issues and Proposed Methods to Address
The project proposes a number of interconnected tools and data resources that will require a considerable realignment of care management of potential stable ischemic heart disease. These changes will require both infrastructure and cultural changes among the stakeholders. It is anticipated that hospital systems and physicians will need to adjust their implementation of the tools and data reporting over time and make incremental adjustments based on lessons learned throughout the project. All stakeholders also will meet quarterly to discuss progress and adjust project components at the end of the first year. It is for these reasons that the standardized components of the project will be limited to required use of the project tools and data but will provide flexibility in their implementation that evolves over time.

Funding
The estimated two year cost of this project exceeds $2 million dollars with significant infrastructure and clinical process flow changes required upfront. The project will seek initial seed funding from each stakeholder that should raise $350,000 - $500,000. The remaining funding will need to come from hospital payments under the proposed episode of care. The major payment reform would need to be supported by CMS through CMMI to allow the payment reform to represent a substantial enough amount to allocate and sustain the necessary resources and tools within hospital system.

Expected Financial Model
Savings from this model for the health care system are expected from three sources:

1. Reduced inpatient, device and ancillary costs from fewer procedures
2. Reduced inpatient facility, device and ancillary costs through bundling
3. Reset base cost for delivery of these services (year over year) resulting in inflationary savings

Savings will be distributed through the payment model to support:

1. Reallocate professional time
2. Data collection
3. Tool licensing and use
4. Health care system savings to health plans, employers, and patients

Financial Projection
In 2010, there were 13,683 stenting cases performed in Wisconsin. On average, 30% of those cases are elective PCIs that would be the target of this project representing 4,105 cases. Based on prior research on shared decision making implementation, up to 20% of invasive procedures may be avoided. Using a reimbursement rate of $15,000 per PCI case for the inpatient, device and ancillary costs the estimated savings for various scenarios are shown below. These savings represent the statewide opportunity if all facilities participated. This project aims to enroll four to five sites representing a significant number of the cases performed in the state. The episode of care payment model would build some of these savings into the case payment rate for the professional, outpatient, and care management fee. As a result, systems would have the opportunity to support this shift in approach to the management of these patients while other stakeholders would avoid the costs and complications of procedures for these patients. Device manufacturers would lose incremental revenues from fewer procedures ($1500 to $2000 per stent). Hospitals would have a decrease in incremental catheterization laboratory and inpatient days related to the change in patient procedures, but would partially offset these decreases by sharing in the savings produced under the new payment model.

Sustainability
The project proposal is build around the assumption of the payment model supporting the implementation financially over time. The clinical and operational components of the project will be supported by the individual stakeholders based on lessons learned during the two year project. Some components may be enhanced while others may be altered or ended based on their contribution to the success of the project. The data dashboard will be used to examine additional areas for potential extensions of this project. Other areas of cardiac care and medicine more broadly also will be examined to identify areas where similar project components and payment components could be implemented or developed.

Project Budget
The proposed project budget is $1.4 million for year 1 and $1 million for subsequent years. The budget supports tool licensing and integration, data dashboard development, payment model design, and project management. The project costs will be covered by seed funding from stakeholders during the first year ($350,000 - $500,000) with the difference and future years covered by the payment model change.

Proposed Timeline

Proposed Timeline for Project

May 11:
Stakeholder meeting and introduction to two page concept proposal

May 12 - June 17: (five weeks)
Project proposal development outlining project components, governance, stakeholder roles, and implementation

June 20 - July 1 (two weeks):
Distribute project proposal to WI stakeholders and CMMI and receive feedback

July 5 - July 13 (two weeks):
Modify project proposal based on feedback and answer questions with individual stakeholders

July 18:
Stakeholder meeting to discuss outstanding project proposal questions and seek final commitment

July 29 (two weeks):
Submit proposal to CMMI for funding consideration

Fall 2011:
Funding commitments and CMMI response

January 2012:
Project commences/Training, installation, and programming

April 2012:
Tools and data dashboard operational

January 2013:
Interim project evaluation and adjustment of project components

January 2014:
Final project evaluation and determination of continuation