Guarantee addresses complications, billing payer

(In this second of a two-part series on innovative care and pricing plans being used for outpatient surgery, we tell you how a facility offers a guarantee involving complications and billing insurance. In last month's issue, we told you how Geisinger Health System in Danville, PA, has used a checklist of best practices to save money, plus implemented a price guarantee for members of its health plan.)

St. Luke's Hospital & Health Network in Bethlehem, PA, offers a surgical guarantee as part of a partnership with urogynecologists at The Institute for Female Pelvic Medicine & Reconstructive Surgery (IFPM) in Allentown, PA.

If a patient develops specific complications directly related to the mesh pelvic reconstructive surgery within 30 days of surgery, the patient and her insurance company will not be billed for services rendered by St. Luke's or participating gynecologic surgeons for the initial surgery or the follow-up care.

Vincent Lucente, MD, chief of urogynecology at St. Luke's, said, "The partnership between the hospital system and our practice is a trailblazing relationship enabling us to realize the concept of 'pay for performance' or 'nonpayment for nonperformance.'"

When developing the guarantee, the surgeons and hospital administrators developed a step-by-step plan. The team approached those steps as a standard protocol for all four of the surgeons at IFPM, so that the same process is followed for each patient, every time, regardless of which surgeon performs the surgery. The resulting multi-faceted plan follows the patient prior to surgery, through the procedure, during her short hospital stay, and during recovery.

Donna Sabol, MSN, RN, vice president and chief quality officer at St. Luke's, said this is the hospital's second surgical guarantee. The first was developed for inpatient robotic prostate surgery in September 2008. The administrators anticipate adding others, including at least one in 2010, but that procedures has not yet been identified, she said.

"The reason for implementing the guarantee is that we are so confident in the skill of the surgeons and the health care team and outcomes, that it's a way to say to patients, 'this is a good program, a quality program, and we're willing to put something behind that.'" Sabol says. "Patients have told us that for them, it adds a lot of confidence."

While the data from the pelvic procedures haven't yet been compiled, the robotic prostate surgery guarantee has resulted in about a 25% increase in volume, she says. Additionally, the hospital has not lost any money due to complications under the pelvic or prostate guarantees, Sabol says.

Before the guarantees were added, the hospital examined the data and knew they weren't having the kinds of complications covered under the guarantee, she says. "We felt confident we could do the guarantee," Sabol says. While no health system can expect to have zero defects forever, "that's what we're shooting for, and that's what we've been able to do up to this point."

Extensive education with the nursing and OR staff is critical to understanding the procedure, as well as the guarantee, Sabol says. "For example, for the nursing staff and the aides on the med/surg unit, we actually had them observe a procedure in the OR or observe a video of doctor . . . doing surgery. So they understand what's happening in surgical procedure and can explain to the patient and reinforce what the doctor . . . teaches them about the procedure itself."

Before adding a guarantee, meet with your surgeons, nurses, and other OR staff to identify what you're doing well and where improvements need to be made, she says. "Get everything clearly written on paper."

Your team needs to ensure that you not only have a written guarantee, but also patient education materials and care order sets, Sabol says. Also, involve your legal advisors in the wording of the guarantee, she says. Marketing also plays a critical role, Sabol says. "It's not good if no one knows about it," she emphasizes.

At the time of the launch of the pelvic procedure guarantee, St. Luke's sponsored the 2009 U.S. Women's Open at a nearby country club. Because incontinence is a quality-of-life issue for women, the staff thought the guarantee tied in nicely with women's sports, says Denise Rader, marketing director for St. Luke's.

The health system held a press conference as part of the tournament kickoff, Rader says. The conference included a female patient giving a testimonial about how she was unable to participate in sports, including golf, because of incontinence issues. The marketing department also contacted urogynecological and medical journals, as well as the local media. Information about the guarantee also was added to the web site. Two weeks later, Lucente appeared on Good Morning America Health to discuss the procedure.

St. Luke's says the guarantee has enhanced the relationship between the hospital and the private group of surgeons who perform the pelvic procedures. Sabol says, "It shows how, when you have good working relationships and professional, direct, and open dialog between surgeons and administrators, they trust you can do some good things for patients." (Editor's note: to see a copy of the limited guarantee, go to www.mystlukesonline.org/docs/pdf/urogyn-termsandconditions5_3__v3.pdf. To see the patient acknowledgement, go to www.mystlukesonline.org/docs/pdf/urogyn-ptacknmt4_2__v3.pdf.)