7 pillars for success with bundled payments: Orthopedics and beyond

Practice Management

Healthcare is moving toward value-based care, and with this transition comes the move toward bundled payment initiatives. Healthcare providers looking ahead into healthcare's pay-for-performance future may reap great financial success if they meet CMS' Comprehensive Care for Joint Replacement requirements.

 "There is a disruptive change coming, and we view this as an opportunity to improve care for our patients," said Joseph A. Bosco, MD, professor and vice chair of New York City-based NYU Langone's orthopedic surgery department.


During an executive roundtable hosted by Pacira at Becker's ASC Review's 23rd Annual Meeting in Chicago, Dr. Bosco delved into what makes a fruitful bundled payment initiative and what has worked at NYU Langone over the past five years during his presentation titled "The Seven Pillars of Bundled Payment Success: Orthopedics and Beyond."


Here are the seven pillars for bundled payment success:


1. Care coordination throughout the episode. In a bundled payment, the episode extends far beyond when a patient is physically in the center, and care coordination is pertinent to ensuring superior outcomes. NYU Langone employed a clinical care coordinator for a successful care coordination process, who fulfills a series of roles including:


•    Calling the patient and family to alleviate any concerns they have before coming in for the procedure
•    Setting the patient's expectations for the hospital stay
•    Assessing the patient's risk and level of care needs
•    Working with both the patient and clinical team to plan the discharge procedure prior to admission
•    Identifying support persons and a patient's pharmacy to facilitate a smooth transition to the next phase of care


When NYU started its CJR bundled payment initiative five years ago, they invested in five care coordinators. Dr. Bosco noted the hospital would hire less coordinators if they were to implement the program now due to the available technology that allows less people to care for more patients.


"The care coordinator does everything from pre-admission to post-discharge. It is important to invest in these people," he added. "The infrastructure you develop in managing bundles trickles down and provides benefits to non-bundled payments and to non-orthopedic issues. Bundling for cancer and cardiac issues is coming. Bundled payments are here to stay and will increase."


2. Preoperative identification and modification of patient factors. Providers can determine high-risk patients and work to lower this risk prior to a procedure or reschedule a surgery based on the identified risk factors.


"As a provider, you are not ethically obligated to operate on everyone for an elective procedure," said Dr. Bosco. "Instead, you can recommend delaying surgery until the patients' modifiable risk factors are addressed. This process results in better care for the patient and a greater chance for success in a bundled payment environment."

Dr. Bosco explained if a patient has five or six identified risk factors, their risk of being readmitted is 20 times higher than patients without these risks. Therefore, providers can identify such patients, provide them the necessary tools which ultimately will work to change their behavior and lower their risk.


Screenings for modifiable risk factors include Methicillin-resistant Staphylococcus aureus screening and decolonization, Hepatitis C screening, aggressive weight control as well as drug and alcohol interventions.


3. Evidence-based clinical pathways. These pathways will help facilities standardize their care. Dr. Bosco noted every intervention within these pathways should add value and the provided level of care should be appropriate for each patient. For instance, some patients may not need certain tests, and fully assessing what level of care is appropriate for each patient will help improve care and lower costs.


Dr. Bosco emphasized the importance of managing a patient's pain and having sufficient pain management protocols in place. Like other hospitals throughout the nation, NYU Langone has worked to enhance their pain management protocols and employs a multimodal approach to pain management. They have made a continual effort to reduce opioid use, which Dr. Bosco noted resulted in patients feeling better and getting out of the hospital sooner.


4. Identify and align stakeholders. CMS launched its Medicare Access and CHIP Reauthorization Act of 2015 to tie payment to quality outcomes and a key aspect of MACRA is getting physicians involved in alternative payment models.


When physicians are involved in an APM, they are dedicated to ensuring the facility is complying with CMS' many requirements. Gainsharing agreements are another key way to align stakeholders. While such agreements were outlawed in years past, MACRA welcomes these types of agreements if facilities abide by all set requirements.


CMS requires providers to comply with a series of rules for eligibility, including but not limited to:


•    Adherence to all CMS hospital quality improvement program and HQA performance data reporting requirements
•    Physicians must voluntarily participate in provider incentive programs.
•    Each provider incentive program must have a committee of hospital administrators and physicians or other appropriate practitioners that develops and monitors progress to assure quality


5. Maximize and demonstrate quality. Facilities can succeed in bundled payments when they identify the metrics important to payers. As healthcare moves toward value-based care, the patient experience comes increasingly into play and dictates reimbursement.


"In the CJR model, a disruptive physician can lead to poor outcomes and inferior care, so hospitals should not accept these behaviors and if the physician refuses to change; they must consider letting go of that physician," said Dr. Bosco.


Hospitals may be eligible for reconciliation payments if they meet the performance threshold for reporting quality measures and other requirements.


6. Implement a robust data collection and dissemination infrastructure. Providers have a wealth of data available at their fingertips, but the challenge rests in making effective use of that data in real time.


"If you have an issue with readmission rates or surgical site infections, you want to know them at the time," Dr. Bosco said. "Institutions with the best, real time data have the competitive advantage."


7. Control post-discharge costs. Dr. Bosco cited a study analyzing a model two bundle initiative for patients undergoing lower extremity joint replacements. The study found that the majority of savings accrued from this model were from the post-discharge period, while the inpatient costs per episode did not change. The BPCI model lowered the episode's average cost from $37,000 to $32,000 and utilization of skilled nursing facility dropped 20 percent.


"We all thought that when we started sending patients home, their length of stay would go up. This is false. We can control them at home. When they are in nursing homes, we aren't controlling them," he said.


Dr. Bosco noted the data that institutions disseminate throughout their organization should be physician-specific so they can make use of the data to drive change in their practice.


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Top 10 areas in healthcare for the next President & Congress to address

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