best practice tariffs for day surgery: does it pay? · • redesigning the pathway to maximize...

British Association of Day Surgery www.bads.co.uk

Best Practice Tariffs for Day Surgery: Does it pay?

Mark Skues

President

British Association of Day Surgery


Remits

• An update and overview on Best Practice Tariff

• Redesigning the pathway to maximize income, day surgery and reduce length of stay

• Engaging and educating clinicians in tariff and optimizing ways of working

• List combination optimization for economic viability


Overview

• What is Tariff?

• History of Best Practice Tariff

• What’s in it for you?


What is Tariff?

“From patient notes to pound

notes”


What is Tariff?

One payment for an operation funds everything.


How it works

Operation

• OPCS classification (>8900)

• Cholecystectomy: J18.3

• Laparoscopic: J18.3 + Y75.2

HRG Code

• GA10C Open Cholecystectomy without CC

• GA10D Laparoscopic Cholecystectomy with length of stay 1 day or more without CC

• GA10E Laparoscopic Cholecystectomy with length of stay 0 days without CC

• GA10F Open or Laparoscopic Cholecystectomy with CC


How it works

CC

• Co-morbidities – Additional conditions that the patient might come into hospital with that increase the complexity of the primary intervention

• Complications – Events during treatment that again increase complexity


How it works

CC

• Co-morbidities • Old myocardial infarction

• Chronic ischaemic heart disease, unspecified

• Atrial fibrillation and flutter

• Chronic obstructive pulmonary disease, unspecified

• Insulin-dependent diabetes mellitus without complications

• Rheumatoid arthritis, unspecified

• Calculus of gallbladder without cholecystitis

• Unspecified disorder of adult personality and behaviour


How it works

CC

• Complications • Acute laryngopharyngitis

• Hypotension due to drugs

• Cardiac arrhythmia, unspecified

• Volume depletion

• Fluid overload

• Disorientation, unspecified

• Cardiac arrest with successful resuscitation

• FB accidently left in body cavity or op wound following a procedure


How it works

Care • Elective or Emergency?


History of Best Practice Tariff


Financial Incentivisation

Four years ago;

Approach to BADS by the NHS PbR Team

“How do we provide appropriate payment for Day Surgery activity?”

• Reduce tariff based on reduced cost?

• No... Enhance tariff as a financial incentive


Laparoscopic Cholecystectomy: ‘Best Practice’ Tariff

2009:

Day case: £1365

In-patient: £1365

For 2010-11: Day case: £1694 In-patient: £1369


Further Day Case Incentivisation 2013-4

Breast Surgery: Mastectomy, SLNB, Axillary Clearance

ENT: Tonsillectomy, Septoplasty, Mastoid Ops

Orthopaedics: Dupuytren’s, Subacromial decompression, Bunion ops

Gynaecology: Female incontinence surgery, O/P Hysteroscopy/Sterilisation

Urology: Resection of Prostate, O/P Cystoscopy

General Surgery: Laparoscopic Cholecystectomy, Hernia Repair


Best Practice Tariffs 2013-14 Day Case I/P

Axillary Clearance £1889 £1589

Mastectomy £2020 £1720

TVT £1126 £926

Hernia Repair £1102 £802

Subacromial decompression £2595 £2395

“Bunion” ops £832 £632

Dupuytren’s Fasciectomy £2479 £2279

Laparoscopic Cholecystectomy £1694 £1369

Tonsillectomy £1106 £806

Septoplasty £1111 £911

Mastoid Ops £2126 £1826

With CC

£2023

£2163

£1126

£1309

£2595

£1234

£2479

£2233

£1254

£1183

£2389


Best Practice Tariffs 2013-14 Day Case I/P

Axillary Clearance £1889 £1589

Mastectomy £2020 £1720

TVT £1126 £926

Hernia Repair £1102 £802

Subacromial decompression £2595 £2395

“Bunion” ops £832 £632

Dupuytren’s Fasciectomy £2479 £2279

Laparoscopic Cholecystectomy £1694 £1369

Tonsillectomy £1106 £806

Septoplasty £1111 £911

Mastoid Ops £2126 £1826

2012

£2053

£2206

£1222

£1136

£2613

£1257

£2735

£1694

£1035

£1183

£1949

Elective operations, without CC enhancement


Running costs for theatre?

The Productive Operating Theatre

?

?


Theatre Cost Context

An operating theatre costs between £12 and £20 per minute to run

~£4000 per operating session

• Staffing

• Environment

• Infrastructure support

• Consumables


Hernia repair BPT Payment for Day Surgery = £1102

(Inpatient care = £802)

Open Repair

‘Heavyweight’ ‘Lightweight’

GA LA

Laparoscopic Repair

TEP TAPP

‘Patch’ ‘Plug’

Mesh Type

Patient Gender, Age, Symptoms, Site, Co-morbidity

Mesh or suture Mesh Type

Size of Mesh


Hernia repair BPT Payment for Day Surgery = £1102

(Inpatient care = £802)

Patient Gender, Age, Symptoms, Site, Co-morbidity


• 10% lists cancelled

• 7.5% gap time

Theatre Utilisation (2003:Audit Commission)


Theatre Utilisation (2005:HCC)


Orchard et al. Journal of One Day Surgery 2011;20.1:4-6.

Theatre Utilisation

80%


Theatre Utilisation

Orchard et al. Journal of One Day Surgery 2011;20.1:4-6.


Lost Theatre Time

Unnecessary effort

Stress for crew

Delays for patients

Crew Efficiency

Long ChangeoversLate Starts

Lost Sessions

Crew scheduling

Late list changes No core crew

Staff Arrival

Prior

past experience

No sense

of urgency

Patient Readiness

Not Yet

consented

Not Decided

Anaesthetic

Late from

Ward

Not called

early

No coordination

of start

Set-up time

Many

Trays

Prep room

too small

Uncertain about

listed procedure

Equipment

issues

Clear-up time

Many trays

Only available

break time

Next Patient Readiness

Not called from Theatre

Not set-up on table

Not set-up on

table correctly

Patient Cancels

unwilling / inconvenient

Unfit – no time to recover

No substitute

patient in time

Trauma overrides elective list

Mass emergency Procedure requires

consultant

Rotation Not self managing

Still consenting

/ briefing

Instrument Delays

Recover from Error

Rep

Availability

Complex

Procedures

Scrub Nurse

Experience

Technician

Availability

Double Preparation

Rep

AvailabilityUnclear lists /

Self confidence

Confidence in

equipment

Confidence in

SSD

Incomplete Trays

Incorrectly re-packed

Wear & Tear

Tray Pillaging

Consumables

not separate

Late list

changes

Instrument

failure

Turnaround time

Chase trays work

intensive for SSD

Transport of

instruments

Basic

tracking

Many

trays

Late notice of

requirement

No warning they

need a translator

Theatre Utilisation


The Engine Room of Day Surgery


GP Surgical

OPD Pre-op

Assessment

Diagnostics Day Surgery Waiting List

Admission and Surgery

Inpatient Waiting List

Post-op Recovery

Day Unit

Inpatient / Short Stay Unit

Unanticipated overnight admission

Discharge

Immediate Post-

operative support

Booking

The Engine Room of Day Surgery


Best Practice Tariff: Lap Chole

HRG Operation Elective Emergency

GA10C Open Cholecystectomy without CC

£2233 £3942

GA10D Laparoscopic Cholecystectomy with length of stay 1 day or more without CC

£1369 £3099

GA10E Laparoscopic Cholecystectomy with length of stay 0 days without CC

£1694 £1290

GA10F Open or Laparoscopic Cholecystectomy with CC

£2233 £4564


What’s in it for you?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Day Case Laparoscopic Cholecystectomy


£0

£20

£40

£60

£80

£100

£120

£,0

00

Op

po

rtu

nit

y

What’s in it for you? Additional BPT payment per year

Day Case Laparoscopic Cholecystectomy


What’s in it for you? Additional BPT payment and saving

on overnight bed costs per year

Day Case Laparoscopic Cholecystectomy £0

£50

£100

£150

£200

£250

£,0

00

Op

po

rtu

nit

y


To qualify for Day Case BPT...

Planned management intent must be Day

Surgery


An example... D/C Tonsillectomy

0

10

20

30

40

50

60

70

80

90

100 Day Case Rates

Day Case + Zero Length

Of Stay Rates

Day C

ase

Rate

(%

)


Future plans for Best Practice Tariff?

PbR now administered by Monitor

Appears to be embedded in DH thinking.

Evaluation in 2011 by the PbR Team


“The NHS Institute for Innovation Improvement...They

brought in a cholecystectomy rapid improvement

programme last year and the large thrust of it was to say

that up and down the country we need to be doing more

and more of our gall bladders as day cases and that led to

me being the lead clinician on the surgical side and then a

colleague who was the anaesthetist backed up by various

managers, senior nursing people and so forth to look at

implementing day case laparoscopic cholecystectomy

which, up to then, we hadn’t really done... about thirty

percent of our gall bladders are being done as day cases

which is right up from virtually zero percent a year or two

previous to that.”

(IID22, Consultant Surgeon, Provider)

Best Practice Tariffs (BPTs) Evaluation Report June

2011


“...One is the day case rate for cholecystectomies and I

find that I’m a bit uncomfortable about that. Because that is

really interfering into the processes of medical treatment in

a way where the guys that sit in the British Association

of Daycase Surgery and all the real cranks. They have

their weird and wonderful little ideas but whether that is

then able to be rolled out across the whole of the UK I think

is doubtful. And to push people to adopt that before they

feel clinically comfortable is, I’m not so sure about it.

Having seen a few people who cholecystectomy actually

they feel like a horse hit them the day of surgery we are ….

kicking patients out rather than letting them sleep...I

don’t think it necessarily enhances their quality of care”

(IID54, Medical Director, Provider)

Best Practice Tariffs (BPTs) Evaluation Report June

2011


NHS Atlas of Variation


Day case Laparoscopic Cholecystectomy


0

10

20

30

40

50

60

70

80

0

10

20

30

40

50

60

70

80

1998

2012

English hospitals

%

Day case Laparoscopic Cholecystectomy


Day Case Mastectomy

0

10

20

30

40

50

60

70

80

%

English hospitals

2012


Optimising BPT income

• Ensure that the ‘Day Case Management intent’ box is ticked

• Ensure that co-morbidities are recorded and coded appropriately

• Maximise the use of your theatre sessions


Best Practice Tariffs for Day Surgery: Does it pay?

Mark Skues

President

British Association of Day Surgery

best practice tariffs for day surgery: does it pay? · • redesigning the pathway to maximize...

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