Some employers are beginning to contract directly with provider organizations for healthcare. 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 recently spoke with Brittany Cunningham, D.N.P., M.S.N., R.N., who has led efforts to launch and expand VUMC’s direct-to-employer commercial bundles 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 for the Episodes of Care Office under Population Health at Vanderbilt. Could talk a little bit about your nursing background and how you came to lead this program?
Cunningham: When I think back, I never imagined that I would be doing something like this. I didn't even know it existed when I got into nursing 20-something years ago. I have been at Vanderbilt for going on 22 years. I was the quality and patient safety advisor for the Heart Institute. As CMS started putting more focus on value-based care and decreasing cost 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 got my first taste of bundled payments. Then Vanderbilt said we needed to start focusing more on this. I started this office in 2015. At one time we were doing over 40 populations with Medicare. The State of Tennessee also does Medicaid episodes of care. Then we started focusing on the direct-to-employer commercial 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 it to the commercial side and developed it ourselves.
HCI: Is there a difference between how you do bundles in direct to employer vs. in Medicaid or Medicare?
Cunningham: There are some similarities, but I think the biggest difference is the way that we have structured our definitions. We go directly to our clinicians and say, don't worry about the payer. We are very clinically focused. We let them decide the way they want to provide the care for the patient, and what they feel is best evidence-based care. Then we create a payment model around it. With Medicare and Medicaid, they are coming to us as the payer and they are trying to cut costs out of the system, and then we have to provide the clinical care underneath it. So we're flipping it around. We say what is the best clinical care possible — and then we put a payment model around it.
HCI: Is one of the goals eliminating clinical variation? Do clinicians have to agree on what the best evidence-based thing to do is and then everyone in the department is going to follow that?
Cunningham: Yes, absolutely. Everyone has to agree to this pathway. A really great example is C sections. For our maternity bundle, we have a blend of vaginal and C-section rates. We have one price for that together, so it's a locked-in utilization rate. So if you go over that utilization, you're not going to 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 that incentive away from the providers to do something just to do it.
HCI: But does that lead to interesting conversations between the clinicians as they try to come to an agreement?
Cunningham: That’s a really interesting question. We are talking to a new provider group about the C-section conversation and they are really excited about it because they feel they get penalized by some payers for their C-section rate. We are actually incentivizing them to do the right thing, which is if you don't have to do a C-section we will incentivize you to not do that C-section, where there are payers that are just ratcheting down that goal of C-sections and not incentivizing them to do the right thing.
HCI: Is one aspect of this improved communication with the patients — perhaps more digital communications so that so they're clear what to expect to happen through the episode?
Cunningham: In creating the bundle, we really focused on three different parts. We focused on the clinical care. We focused on the financial portion, which is that payment model and it's a locked-in price, so there's predictability for the employer, and transparency for that.
The other key part is that we waive the patient portion, so we're giving cost savings to the patient also. And then we focus on the experience. How do we make this a better experience for the patient? We didn't want to just put lipstick on a pig. We wanted to actually make it a better experience. We added patient navigators, who walk patients through the bundle. For maternity a bundle can be as long as 12 months long, so understanding what's included and what's not included is important. The navigator is there for any question that's not clinical-related. The patient can call for directions, for getting an appointment scheduled. For any question, they have that one point of contact. The navigator will send information to the patient at key points during the bundle and during the journey. So instead of giving a book of education and a bulk of information, they'll send little e-mails or little pieces of information at key points. We broke it down so we didn't overwhelm the patient and it really helps the patient understand what to expect.
HCI: Have you gathered patient-reported outcome data on the back end to compare that to a control group of people who aren't in a program like this?
Cunningham: We do collect functional patient-reported outcomes for our ortho patients, but we have not done that comparison yet of whether their patient-reported outcomes are different than for the non-bundle patients. I think that's in our future. We do have survey data, which is patient satisfaction data. Our net promoter score is is extremely high. It's in the eighties, and it has been for a couple of years now. We also have outcomes data like C-section rates. Our C-section rates are lower than the non-bundle patients. Another interesting data point is that our NICU rates are lower.
HCI: Can you gauge the employer satisfaction, either through continued participation or growth in the program?
Cunningham: We've had a few key employer since the beginning. We currently have five employers on contracts. Those employers who have been with us since the beginning have added more programs. One employer said they wanted to start with maternity and then about six months later they said they were going to add more programs. We just talked to them recently and they're interested in adding even more programs, so they see the benefit of it and they see that their members are appreciating the benefit.
HCI: Do the employers you work with have to be self-insured?
Cunningham: They do have to be self-insured. And the reason is because the rules around self-insured vs. fully insured. Fully insured is not as flexible, but with self-insured, you’re essentially writing your own rules of your benefits, and you can be more flexible with adding value-based programs like this.
HCI: You’ve added quite a few different bundles over the years. Vanderbilt has developed bundles around maternity, hearing, spine, orthopedics, weight loss, urology, substance use disorder, and cardiology. Are there even more things that could be put into a bundle?
Cunningham: We have that conversation a lot. What is the limit of what can be bundled? I think there are more that can be. If you're familiar with bundle programs, everybody kind of goes after the ortho stuff first. We figured that's what we would do. But then we started talking with one of our employer partners and they said that maternity is what they needed. Maternity was where their high spending and variability was. That's what they needed help with, so we pivoted and we did maternity first, which was very beneficial because that was 2019. And we started in 2020. That was when COVID hit, and we still did ortho right after that. We had so much volume coming through with maternity and we learned a lot about how to administer this and how to change the definitions. We try to listen to our employers and our partners and ask: Where are your pain points and what do you need? We get a lot of feedback. I just heard recently that they want a diabetes bundle. There are programs that we can create that are value-based care so that it's helping them with their spend, and making a better experience for the patient.
HCI: At about 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 kind of pioneering some of this work?
Cunningham: Five years ago, I would say, there were not very many out there. There were a couple doing more of the “centers of excellence” model, which is really focused on procedures and not the comprehensive model like we were creating. And then there's the Medicare model. So those were the two that we could look at, but not the way that we wanted to structure it, which is the more comprehensive experience and the risk that we wanted to take on. I've talked to a lot of institutions across the nation and more are trying to get into this space and move in the direction that we have moved, which is great. I love that there are more people wanting to do it. And some are willing to take on the risk that we have taken on, but I would say that there's only a handful.
