Bundled payments are an alternative delivery model offering orthopedic surgeons performing total joint arthroplasty an ideal opportunity. TJAs are perfect for bundling, as they're defined episodes, easily comparable, high volume and paid for by the government in most instances.
Bundling could not exist without the evolution of technology such as EMRs, noted Joseph Bosco III, MD, vice chairman of clinical affairs and director of the Center for Quality and Patient Safety at New York City-based NYU Langone Orthopedic Hospital, during a Pacira Pharmaceuticals-sponsored webinar Oct. 16, hosted by Becker's Hospital Review.
But organizations should ensure new technology creates a positive incremental cost-effectiveness rate, which measures every new intervention cost increase against the amount of outcome improvement.
"In medicine, it's ethically not tenable for any decrease in cost to come with any association in decrease of outcomes," Dr. Bosco said. "If you want to increase value, the best way is decreasing costs while improving outcomes."
7 clinical pillars of bundled payment success
Since implementing a bundled payment program in 2013, NYU Langone has learned seven key lessons for success by leveraging technology.
"We've had all successful reconciliations with CMS over our bundled payment program, but as we went through the program we discovered different clinical pillars of bundled payment success," said Richard Iorio, MD, chief of the division of adult reconstructive surgery at NYU Langone Orthopedic Hospital.
1. Optimize patient selection. NYU Langone leverages technologies to enhance care coordination pathways and implant selection. Dr. Iorio said they quickly realized the impact of comorbidity burden on operation outcomes. Specifically, certain comorbidities increased risk of adverse outcomes or complications. The hospital developed several tools to stratify patients with comorbidities into readmission risks, such as the Perioperative Orthopaedic Surgical Home and the Readmission Risk Assessment Tool.
"We've quantified the readmission rates for these comorbidities," explained Dr. Iorio. "Patients with many comorbidities can have 10 to 20 times higher rates of readmission than standard-risk patients." The average national 90-day readmission rate for Medicare patients is 18 percent, but the Perioperative Orthopaedic Surgical Home program decreased readmission rates at NYU Langone to 5.8 percent.
"We're not denying care to these patients. We're just delaying the joint replacement until they can modify their risk factors," said Dr. Iorio.
2. Optimize care coordination, patient education and expectations. Bundles will not work without excellent clinical management throughout the pathway. Bundles involve a variety of care settings, from inpatient to post-acute care. Dr. Bosco recommended one person coordinate a patient's entire care journey to ensure patient handoffs are seamless.
"It is important that technology be leveraged, and it can be in the form of web-based follow-ups, check-ins and physical therapy," explained Dr. Bosco. "Using technology to keep track of the patient throughout every part of this episode is highly important."
To ensure coordination across an entire episode, an organization will need to align clinical management, technology and clinician behavior. This way, the message to any patient will prove identical during any episode.
3. Use a multimodal pain management protocol and minimize narcotics. NYU Langone combines multimodal drugs, injections and anesthesia techniques to control pain and limit narcotic use.
The hospital reduced the use of femoral nerve blocks and patient-controlled analgesia following surgery. Additionally, they introduced liposomal bupivacaine to complement periarticular injections for pain management in the first 36 to 48 hours.
This multimodal pain approach to TJA bundles allowed NYU to:
• Achieve equivalent pain control
• Reduce narcotics
• Achieve faster patient mobilization
• Decrease fall rate
• Decrease length of stay
• Boost discharge to home as opposed to post-acute facility
• Improve pain-related HCAHPS scores
• Reduce hospital cost
4. VTE risk standardization and optimized blood management. Blood clots and venous thromboembolism events are common following joint replacements. Thus, it's critical providers find ways to reduce these complications to increase bundled payment success. To minimize blood clots and VTEs, Dr. Bosco suggested risk stratification.
"We have a risk stratification score on our EMR that everyone fills out; if that score is a certain amount, it steers clinicians to a certain VTE prophylaxis regiment," explained Dr. Bosco. At NYU Langone, they found risk-stratified protocol patients experienced a lower incidence of VTE compared to patients treated with aggressive anticoagulation.
"By giving each patient the appropriate amount of VTE prophylaxis, we maximized the decrease in VTEs and minimized the rates of infection, and it was less expensive," said Dr. Bosco.
Additionally, the hospital implemented blood management techniques, such as limiting the amount of transfusions, to positively impact patient care and the bottom line.
5. Minimize post-acute facility and resource utilization. A patient's home offers the best place for recovery for 80-plus percent of patients — at least in the New York City area. Dr. Iorio said they discovered patients who were discharged to sub-acute nursing facilities had a readmission risk twice as high as patients who went home.
To address readmission risk, the hospital limited its number of post-acute partners by transitioning to a narrow network. It then communicated best practice protocols to its post-acute partners. NYU Langone possesses telemedicine access with its post-acute partners, and its care coordinators visit patients at these facilities.
"We tend to keep patients in the hospital longer if they're going to need a sub-acute nursing facility, so we can see if they're on the borderline, " added Dr. Iorio. "You can keep people in the hospital up to eight, nine days and still make money on the bundle."
6. Transparent data. Transparent and real-time data are critical to success under a bundled payment model. NYU Langone developed dashboards with physicians' real-time data they can use at the point of care. The data displayed includes quality metrics (VTE, readmissions and surgical site infections) as well as direct cost of index admission and discharge.
7. Gainsharing and alignment. Drs. Bosco and Iorio identified gainsharing as a key way to align physicians with the hospital under the bundled payment program. Gainsharing involves hospitals' payments to physicians based on care quality improvement.
Conclusion
Looking forward, the next major target for value-based TJA episodes will be to purchase value-based implants and enhance home healthcare by way of technology.
"With the integration of technology, we can decrease the amount of touches with the patient, which are less expensive, and use the technology to make sure the continued care is there, but just doing it in a less expensive way," concluded Dr. Bosco.
Listen to the webinar recording here and view the webinar slides here.