As bundle participation declines, orthopedics looks to increased risk sharing and population health: 4 industry leaders discuss

Alan Condon -   Print  |

Recent dropout rates in CMS' Bundled Payments for Care Improvement program indicate that participation barriers and retention strategies need to be addressed to have a more significant effect on healthcare cost and quality, according to an article published in the Journal of the American Medical Association.

For orthopedics, many providers are looking toward increased risk sharing contracts and population health initiatives to pave routes for value-based care. Four industry leaders share their thoughts on the future of orthopedic care delivery:

Note: Responses are lightly edited for style and clarity.

Alexander Vaccaro, MD, PhD. President of Rothman Orthopaedic Institute (Philadelphia):   We were in bundled payments for the last 10 years, and we did great. We had shared savings with the insurance company and with the hospital. What happens is the growth changes every year; the better you get, the more difficult it is to save money, so we're now bottomed out. In the federal government and a lot of their value-based systems, we're actually dropping out a lot of them because we can't get any more efficient.

We can get a hip fracture to the operating room within 24 hours and we can get them out of the hospital to a rehab or a home within one to two days; we've done everything. We looked at everything we could to sort of squeeze out any inefficiencies. The next step is population-based medicine where you do per patient — per member per month, per member per year arrangements.

Anthony Romeo, MD. Executive vice president of DuPage Medical Group Musculoskeletal Institute (Downers Grove, Ill.): We continue to have significant fee-for-service care throughout healthcare, which does not provide the best environment to encourage value-based care. We have moved to some alternative payment models such as bundled payments, but this method typically lacks sustainable incentives. Bundled payments can have the effect of reducing a specific episode of care, but they are not built to eliminate less successful surgeries and it doesn't necessarily reduce overall cost of care. These methods have been interesting efforts to try to improve care and reduce costs, but often the only thing that happens is that a single episode of care has a reduced overall cost, without much impact on the total cost of care for a population of patients. While there have certainly been some reports of significant savings and increased financial benefit to some groups, the inevitable conclusion has been that when the efficiencies are maximized, physician reimbursement is driven to levels below a sustainable business model.

At DMG, working within the value-based care model also means that you look at the whole patient. We look for opportunities to share the risk of patient care by managing the entire patient — being responsible for all of the medical problems and social determinants of health, which will allow us to better manage the overall cost of care and achieve better outcomes. Of course, our role will be focused on the challenges related to the musculoskeletal system. Within the context of the whole organization and the high level of informatics we have, as well as protocols and technology, we want to work towards a model of what healthcare should be in the future.

Wael Barsoum, MD. President and chief transformation officer of HOPCo (Phoenix): My belief is that changes in [Bundled Payment for Care Improvement Advanced] and other programs being considered by the federal government clearly signal a broader shift toward population health, which will be the catalyst to orthopedic care being increasingly delivered in vertically integrated systems that align physicians, hospitals and payers. The main driver of this will be reducing variability and cost while improving patient outcomes. As physicians and health systems take on more financial risk, the ability to manage the entire continuum of care is imperative. Care will shift to lower-cost sites of service, such as surgery centers, and health systems must have a coordinated strategy to maintain volumes and margins in the hospital setting through more integrated value-based care programs and more intensive and effective inpatient care redesign.

Nicholas Grosso, MD. President of The Centers for Advanced Orthopaedics (Bethesda, Md.): We've realized that bundled payments is kind of a race to the bottom. Now what we're looking at is shared savings as a start into value-based care, which works differently than bundles. Ultimately, our goal is to get to where we can take risk on our contracts. That risk is most likely going to have to have upside and downside risk in order to be effective. We're laying the foundation now for us to be able to accept risk in the future. That requires certain strategies to be put in place, such as common EMR and billing across the whole platform and ways to monitor performance. We're implementing these now so we'll be ready in a year or so when the market is better.

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