WOMACK FT Bragg NC Lithotripsy Initiative Urology Business

WOMACK, FT Bragg, NC Lithotripsy Initiative (Urology) Business Case Analysis Synopsis COL Bobbilynn H. Lee U. S. Army - Baylor HCA

Agenda • • • Background Facility Service Area BCA Synopsis Analysis Questions

Womack • • • Fort Bragg, North Carolina Tricare Region 2 Medical Center w/ Level I ER Approximately 157, 000 beneficiaries Clinic Facilities – Joel Health and Dental – Robinson Health Clinic – Clark Health Clinic

Lead Agent Region Two

Duke University Medical Center FT Bragg, N. C.

Business Case Analysis

Background • No ESWL at Bragg – National Standard of Care • Not meeting Tricare Access Standards – 80 miles, 3 -5 week delay • Patients electing stone surgery – Longer recovery

State of the Art Urinary Stone Treatment

Benefit Drivers State of the Art

Stone Composition Calcium Oxalate Monohydrate- 97%, protein and blood 3% Calcium Oxalate (Monohydrate form-10%, Dehydrate form 59%), Calcium Phosphate (Carbonate form- 7%, Hydroxyl form-21%), protein and blood-3% (Gall stone)- Cholesterol- 96%, Calcium Bilirubinate- 2%, Mixed Bile Pigments- 2% Calcium Oxalate Monohydrate- 98%, protein- 2%

Lithotripsy Benefits • • Avoid Surgery for Stone (basket, cut) Continuity of care Quick return to work Meet access standards, 4 weeks, one hour drive

Performance Measures • 32 procedures annually • Direct care - 60 stone cases in OR per year • 60 other cases could be done by freeing up OR space

Goals & Objectives • Recapture $48, 902 Revised financing • Cost avoidance $214, 920 for 90 OR procedures • Eliminate 60 urology invasive procedures a year • Free up 60 surgical suite rooms annually Increased satisfaction due to access • Third Party Reimbursement $22, 222 annually • Recapture 96 ESWLs per year (8/mo) • Recapture 58 surgical cases / year

Measures of Success • Prime/ AD Beneficiaries: – Surgical procedures / OPVs in MTF increase – Surgical procedures/ OPVs provided by Network provider increase – Decrease Revised Financing, Supp care

Measures of Success AD and Prime Pts • 95% reduction in network ESWLs • 95% reduction in stones done in OR • Minimum of 58 fewer referrals to network annually

Alternatives • Equipment Purchase $350, 000 • Resource sharing not an option • Surgery Not Considered: • 1986 Send Urologist to downtown facility • Mobile lithotriptor • Joint Venture with regional facilities

Financial Implications • Recapture $48, 902 MCSC Rev Fin • 60 OR rooms available = $ 214, 920 Cost Avoidance • $1, 929/procedure =$22, 222 Sup Funds • 96 procedures @ $1, 700/proc, $163, 200/yr

Economic Analysis: • 3 year investment $489, 600 • Net ROI on 3 year investment: $225, 200 • Annual target recapture – 96 OPVs – 60 Surgical Procedures • $501 more expensive per procedure than outsourcing

Risks and Interdependencies • Projected loss of Urologist Not Considered: • Number of stone cases

Performance to Date • Started 22 October 2001 • Breakeven 1 Feb 2002 • Reached target – OPVs 145/ mo; target 75 OPV/mo – ESWLS 34/ mo; target 27/mo

Surgeon General’s Site • Army medical command knowledge exchange • https: //ke. army. mil/ • BCAs, all forms, follow-ups • FY 03 Group 2 Venture Capital submissions

BCA Virtues • • Standard of care On track with milestones Extremely well written Beautiful statistics

What Went Wrong • Pay $500 more Per Procedure • Lost Urologist • Workload decreased, no cost avoidance or refinancing recapture • Unable to free up OR room, no increase in OR cases • How many stone cases

Comparative Analysis WBAMC Litho Initiative • Ureteroscopy (surgery) cost vs. ESWL – $134 k(3 k per) 40 pts vs $26, 000 (1 k per) 23 proc • Solicited VA pts as well

Additional Alternatives to Consider • Send military urologist downtown, – save professional fee – Will work for other procedures, Tread mills, etc • Joint venture with regional facilities for mobile unit

Lessons Learned • Look for model, its all been done before • Don’t allow faulty assumptions • Even the best written can be entirely wrong • When in doubt, call a fellow Bear