Clinical and Health Affairs
Minnesota’s Baskets-of-Care Project: Scope, Components, and Measurement
By Cally Vinz, R.N., Joann Foreman, R.N., and Sara Bonneville
Abstract
One idea that has emerged from health care reform discussions in Minnesota is the concept of “baskets of care,” a method of reimbursing health care providers for episodes of care, rather than specific services and procedures. As a requirement of the state’s 2008 health care reform legislation, the Minnesota Department of Health, with help from providers, payers, employers, and consumers, developed baskets of care for pediatric asthma care, diabetes care, prediabetes care, acute low back pain care, obstetric care, preventive care for adults, preventive care for children, and total knee replacement. This article describes those eight baskets of care, their development, and the recommended quality measures for each one.
As Minnesota has focused on reforming health care delivery in recent years, it has become increasingly apparent that our fee-for-service payment model is structured to reward providers for delivering more care rather than higher-quality care. Thus, rethinking the provider reimbursement system has become central to state health care reform efforts. One idea that has emerged in the reform discussions is to reimburse for episodes of care rather than specific services and procedures.
The baskets-of-care project, one component of the comprehensive health care reform legislation signed into law in May of 2008, represents an attempt to do that. According to the law, the Minnesota Department of Health is required to establish baskets of care (ie, bundled services) in the hope that this new way of paying for health care services would inspire health care delivery groups, health plans, and employers to work together to develop innovative ways to deliver high-quality health care services in a cost- efficient manner.
Consistent with Minnesota Statutes 62U.05, providers may choose whether or not to package relevant services as baskets of care and payers may decide whether or not to contract for baskets of care. A payer may only contract for a basket at the price the provider has determined. In other words, the price established by the provider is the same for all payers that choose to contract for the basket. No negotiated discounts are permitted.
To design the baskets-of-care model, Department of Health officials sought input from more than 140 stakeholders including providers, payers, employers, and consumers. The Department of Health contracted with the Institute for Clinical Systems Improvement (ICSI) to facilitate the process by which subcommittees of stakeholders identified eight baskets of care and defined their components. The subcommittees used a number of criteria, including whether there was the potential for financial savings and improving the effectiveness of care, to determine which conditions and procedures should be selected for the first baskets. They also recommended quality measures for the baskets related to clinical outcomes; process; education, coaching, and counseling; functional status; patient experience; and cost. This article describes the results of their work: the scope, components, and recommended quality measures for each basket.
■ Asthma Care for Children
This basket includes services related to comprehensive ambulatory care for children ages 5 to 18 years who have been diagnosed with persistent or intermittent asthma. It is not designed for children with severe cardiovascular and/or other chronic respiratory diseases.
The components of the basket are based on recommendations from the National Heart Lung and Blood Institute (NHLBI) and ICSI guidelines. They include asthma assessment and monitoring (in a case where the diagnosis has already been determined), annual spirometry, medical assessment, asthma education, advice about controlling environmental factors and comorbid conditions, rescue inhalers, and long-term medications. The basket includes care provided by licensed and/or certified medical professionals over a one-year time period as well as care coordination to facilitate communication between health care providers and school nurses and other caregivers. Excluded from the basket are emergency room care and hospital inpatient care.
Recommended Quality Measures
• Documentation of the provider’s assessment of the patient’s asthma control (using NHLBI guidelines or a validated asthma-control assessment tool),
• Assessment and documentation of the patient’s experience with their asthma during the 12 months of care provided in the basket (the number of emergency room visits, hospitalizations, and prednisone bursts),
• Documentation of an asthma management plan that includes a written plan given to the patient, information on medication doses and purposes, guidance on how to recognize and what to do during an exacerbation, and asthma triggers; and
• Assessment and documentation of tobacco use and/or exposure.
■ Diabetes
The scope of this basket includes assessment, monitoring, and outpatient management of adults up to 65 years of age with medically uncomplicated type 2 diabetes. It excludes services for those with advanced or end-stage diabetes-related complications and/or other severe conditions, and patients who are pregnant.
The care components include multi-dimensional medical assessment and lab monitoring (A1c levels, lipids, and liver and renal functions), an eye exam, a nephropathy assessment, and education and coaching on management and lifestyle issues (physical activity, glucose monitoring, and weight control).
Recommended Quality Measures
• A1c test results less than 8.0
• Blood pressure less than 130/80 mm Hg
• Low-density lipoprotein (LDL) level of less than 100 Being tobacco free, and
• Daily aspirin use for patients ages 41 years and older unless there is a documented contraindication.
Process measures include the percentage of patients ages 18 to 65 years who received a dilated eye exam within the appropriate time frame, an annual comprehensive foot exam, medical nutrition therapy within the past year as evidenced by a visit to a registered dietician or documentation the patient received counseling that meets the national standards, diabetes self-management training, and at least one test for microalbumin for those patients with a previous microalbumin level of less than or equal to 300.
■ Prediabetes
Because a growing number of people are at risk for developing type 2 diabetes as a result of the increase in obesity in the United States, the baskets-of-care project participants felt strongly about developing a prediabetes basket of care. For purposes of the basket of care, prediabetes was defined using the current American Diabetes Association acceptable lab measurements:
• Impaired fasting glucose (IFG) IFG=FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) or
• Impaired glucose tolerance (IGT) IGT= 2-h plasma glucose 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) The care components were identified based on the current literature, guidelines, standards of practice, and, in some cases, evidence-informed consensus. They include lab monitoring, management though programs such as the Diabetes Prevention Program (DPP), and follow-up counseling.
Recommended Quality Measures
• Fasting plasma glucose test results of less than 126 mg/dL at one year as evidence of not progressing to diabetes,
• Having a documented plan for moderate weight loss (greater than or equal to 7 percent) of body mass for those with a Body Mass Index (BMI) measure higher than 25.
• Recorded physical activity of at least 150 minutes per week, and
• Being tobacco free.
Additionally, the recommendations included documentation of the patient’s completion of at least 75 percent of the DPP program.
■ Acute Episode of Low Back Pain
The scope of this basket is appropriate and timely care for adults ages 18 years and older with acute low back pain (0 to 6 weeks) or chronic pain with acute exacerbation of a previous episode. It is not designed for patients with Cauda Equina Syndrome, cancer of the spine, infection of the spine, spinal or pelvic fracture, major trauma, major progressive neurological deficit, pregnancy, history of spine surgery within the last six months, and other medical conditions for immediate evaluation and treatment.
The care components include screening/assessment (neurological or pain scale); establishing a care plan; initial treatment/management focused on patient education, lifestyle changes, and lumbar stabilization as indicated; other noninvasive modalities as indicated; and outcome assessment with a validated tool, along with a care plan for maintenance or referral. This basket does not include the cost of imaging, needle injections, or medications.
Recommended Quality Measures
• Percentage of patients with a diagnosis of acute low back pain for which the provider ordered a cross-sectional imaging study (MRI or CT scan) during the six weeks after pain onset in the absence of red flags (eg, suspicion or history of cancer, infection or fracture, uncontrolled pain, or major or progressive neurological deficit);
• Percentage of patients with an initial visual analog scale (VAS) pain rating of 4 or more and an Oswestry score of 20 or higher who had at least a 30% reduction in their Oswestry score at six weeks. This measure should be calculated as initial Oswestry score x 70% = expected score (eg, a patient who has an initial score of 49 and a six-week score of 30 has a reduction of more than 30%);
• An average percent reduction of Oswestry score at six months for all adults patients with a diagnosis of low back pain;
• Total cost of care during the first six weeks of treatment; and
• Cost of care for basket components delivered in the first six weeks.
■ Obstetric Care
The scope of this basket is prenatal services for women with a confirmed, single intrauterine pregnancy from the time of conception to the onset of labor. (It is not designed for patients with high-risk pregnancies (ie, those with HIV, insulin-dependent diabetes, and multiple gestations). The care components include routine prenatal assessments and screenings (10 to 14 visits); counseling/education in 15 areas (eg, preterm labor, nutrition, and weight); discussion of labor and delivery concerns; immunizations and chemoprophylaxis including tetanus booster, hepatitis B vaccine, and influenza vaccine; RhoGAM as indicated; and ultrasound as indicated. Aneuploidy testing is excluded from the basket of care. All services in the basket must be provided by licensed health care professionals.
Recommended Quality Measures
• Tobacco, drug, and alcohol use assessment and BMI assessment, and referrals for counseling when appropriate;
• GC/chlamydia testing, rubella antibody test, syphilis test, HIV testing, CBC/Hgb, ABO/Rh/Ab, urinalysis/culture, hepatitis B serum antigen, gestational diabetes screening through a glucose tolerance test, Group B strep culture, and RhoGAM shots for Rh-negative patients.
• Depression assessment and follow-up if indicated.
■ Preventive Care for Adults
This provides a comprehensive annual health assessment for adults up to 75 years of age, followed by a summary report or care plan based on health risk, age, and gender.
The care components include screening for tobacco use, substance abuse, depression, family medical history, height and weight, and lifestyle risk factors; screening for cancer, diabetes, and osteoporosis as indicated; an immunization review; and preventive counseling, risk reduction recommendations, and referral based on risk assessment.
Recommended Quality Measures
Patient experience score using a standard, validated tool such as CAHPS.
■ Preventive Care for Children
The pediatric basket provides clinical preventive services and health maintenance for children from birth (after hospital discharge) up to their second birthday. It is not intended for the diagnosis and treatment of an acute or chronic condition. If such a condition is identified, other guidelines and recommendations should be used to manage the patient’s care. This basket excludes management of any illness or diagnosis, or treatment of any disease or condition.
The care components include promotion of breastfeeding, immunization assessment, age-specific assessment, education and counseling, vision and hearing assessment and surveillance, and a minimum of eight face-to-face visits and four physical exams. Immunizations are excluded.
Recommended Quality Measures
• Documentation of child being current on immunizations (or refusal by parents),
• Promotion of breastfeeding and continuation three times or documentation if not appropriate,
• Newborn blood-spot screening and documentation of follow-up,
• Vision assessment at each encounter,
• Hearing screening and documentation of follow-up,
• Infant sleeping position and SIDS counseling during each encounter, and
• Patient experience measurement using pediatric CG-CAHPS.
■ Total Knee Replacement
This is for an elective first-time total knee arthroplasty as recommended by orthopedic consultation for adults up to 64 years of age who have a BMI of less than 35 and mild or no systemic disease.
The total knee replacement subcommittee noted that there is no strong evidence-based criteria or functional tool available for patient selection for this procedure. As a result, the scope of the basket of care begins after the provider and patient have completed shared decision-making and the patient elects to go ahead with the procedure.
The care components for this basket include the preoperative phase evaluation, education, and case management; the operative/acute care phase including such things as anesthesia and operating room services, knee prosthesis and medications; care for 90 days following the procedure; and readmission and care for complications related to the surgical site within 90 days of the procedure.
Recommended Quality Measures
• Functional status outcomes that would initially include a preop and 90-day post- op Oxford Knee Score;
• Hospital readmission or any inpatient or outpatient procedure for a complication related to the surgical site within 90 days of the procedure.
Baskets of Care Implementation
It is helpful to think about delivering a basket of care in the same way as you would think of building a house. The provider or provider group that offers the basket of care would serve as the general contractor, subcontracting with other providers who offer components of the basket.
All parties would agree on which services each would provide, their price for those services, how they would coordinate patient care, and how they would approach health plans to secure reimbursement. It is likely that in the beginning all providers involved in a given basket would need to submit their own claims and encounter data, but that the payment would be administered through the basket-of-care “owner,” who would then be responsible for paying the other providers. In the future, the basket-of-care owner may be responsible for gathering and submitting all of the claims and encounter data from the subcontractors.
Providers may begin offering and health plans may begin paying for baskets of care this month. Based on anecdotal reports given at a baskets-of-care summit hosted by the Department of Health in November, some medical groups plan to implement one or more baskets of care in 2010. The Department of Health has posted a number of how-to guides on its website (www.health.state.mn.us/healthreform/baskets) to assist organizations in implementing the baskets-of-care model. These provide information about contracting with other medical groups, administrative and operational issues that should be considered, pricing and risk concerns, and how to approach health plans about reimbursement.
Conclusion
The baskets-of-care development process has provided a significant opportunity for learning, discovery, and collaboration. The efforts of the baskets-of-care subcommittees and the implementation work done to date by medical groups indicate there is much interest in this innovative, collaborative approach to providing high-quality services in a cost-effective manner.
Bundled payment pilots are being launched around the country, and this is one of many efforts to test the use of this payment methodology. It is not yet known whether these efforts will result in a fundamental change in reimbursement. Yet, they are important first steps toward payment reform. MM
*More detailed information about the development, scope, components, and measures for each basket of care can be found at www.health.state.mn.us/healthreform/baskets, or www.icsi.org.
Cally Vinz is vice president of clinical products and strategic initiatives and Joann Foreman is a clinical systems improvement facilitator with the Institute for Clinical Systems Improvement. Sara Bonneville is a program analyst with the Minnesota Department of Health’s health economics program.