Get­ting a leg up on bun­dles

Modern Healthcare - - BEST PRACTICES - By Harris Meyer

This month, hun­dreds of hos­pi­tals in 67 mar­kets across the coun­try started do­ing hip and knee re­place­ments un­der Medi­care’s manda­tory bun­dled-pay­ment ini­tia­tive. Ex­perts say many weren’t pre­pared to meet the tough chal­lenges of the Com­pre­hen­sive Care for Joint Re­place­ment pro­gram, which re­quires hos­pi­tals to pro­vide the pro­ce­dure and all care for up to 90 days af­ter­ward for a tar­get price.

But at least two health sys­tems saw bun­dled pay­ment for joint re­place­ments com­ing and rig­or­ously pre­pared them­selves—CHI St. Alex­ius Health in Bis­marck, N.D., and Pitts­burgh-based UPMC. They con­vened mul­ti­dis­ci­plinary teams of sur­geons, anes­the­si­ol­o­gists, nurses, ad­min­is­tra­tors, phys­i­cal ther­a­pists and other staff to hone their clin­i­cal pro­cesses, pur­chas­ing of im­plants, pa­tient ed­u­ca­tion and post-acute care to op­ti­mize out­comes and re­duce costs. It wasn’t easy.

Their sur­geons had to agree to stan­dard­ize im­plant de­vices. Anes­the­si­ol­o­gists had to ad­just pro­to­cols to re­duce nau­sea so pa­tients could start phys­i­cal ther­apy right af­ter surgery. Nurses and phys­i­cal ther­a­pists had to hus­tle to get pa­tients ready for dis­charge the day af­ter the pro­ce­dure. Pa­tients were asked to lose weight and con­trol their blood sugar be­fore surgery and take charge of their own care af­ter­ward— with far fewer stays in post-acute fa­cil­i­ties. And post-acute providers had to fine-tune their care or be dropped from the re­fer­ral net­work.

In­for­ma­tion tech­nol­ogy and fi­nan­cial align­ment be­tween hos­pi­tals and physi­cians will be ma­jor chal­lenges in mak­ing bun­dled pay­ment work, said Dr. Alexandra Page, who chairs the Amer­i­can Academy of Or­thopaedic Sur­geons’ Health Care Sys­tems Com­mit­tee. Providers have to com­mu­ni­cate across the en­tire spec­trum of care, which is of­ten not hap­pen­ing now. And hos­pi­tals and physi­cians need to agree how to share risks and gains, she said.

St. Alex­ius started its im­prove­ment process about a year and a half ago, af­ter it was pur­chased by Catholic Health Ini­tia­tives. CHI brought to­gether or­tho­pe­dists from its hos­pi­tals—in­clud­ing some al­ready par­tic­i­pat­ing in Medi­care’s vol­un­tary bundling ini­tia­tives—to dis­cuss best prac­tices. Af­ter at­tend­ing those ses­sions, Dr. Tim Bopp, St. Alex­ius’ chief of staff, worked with his col­leagues to shorten length of stay, change anes­the­sia prac­tices, and min­i­mize the use of post-acute fa­cil­i­ties.

The hos­pi­tal as­sem­bled teams to ex­am­ine pre-op­er­a­tive, acute and post-op­er­a­tive care, said St. Alex­ius Chief Nurs­ing Of­fi­cer Rosanne Sch­midt, who led the ini­tia­tive. The staff be­gan ed­u­cat­ing pa­tients on how to op­ti­mize their health be­fore surgery and man­age their wound care. The hos­pi­tal hired nurse nav­i­ga­tors to check up on pa­tients af­ter surgery. And it fo­cused on bet­ter pain man­age­ment.

Due to these ef­forts, St. Alex­ius, which does about 800 to­tal joint re­place­ments a year, says that since March 2015 it has cut av­er­age length of stay from 2.5 days to 1.7 for knees and from 2.6 days to 1.79 for hips. It re­duced the com­pli­ca­tion rate for both pro­ce­dures from 1.87% in the first six months of last year to 0% for the past six months. And it’s send­ing only about 8% of pa­tients to skilled nurs­ing or re­hab, com­pared with nearly 30% in 2010.

UPMC, which does nearly 6,000 joint re­place­ments an­nu­ally in the Pitts­burgh area, launched its bun­dled pay­ment ini­tia­tive in con­junc­tion with the UPMC Health Plan in 2012 when its lead­ers iden­ti­fied lots of vari­a­tion in care, said Chief Qual­ity Of­fi­cer Tami Min­nier. Early on, the sys­tem de­vel­oped an in­pa­tient path­way that cut use of blood trans­fu­sions by sur­geons over the two-year pi­lot—from more than 10% of cases to 1.1%.

The sur­geons also re­duced vari­a­tion in sur­gi­cal sup­plies, in­clud­ing im­plant de­vices, said Dr. MaCalus Ho­gan, a UPMC ortho­pe­dic sur­geon who co-led the im­prove­ment ef­fort with Min­nier. UPMC also de­vel­oped a “pre­hab” process to help pa­tients pre­pare for surgery and re­cov­ery. UPMC nar­rowed its pre­ferred post-acute provider net­work to its own four skilled-nurs­ing fa­cil­i­ties and seven out­side part­ners.

The changes made dur­ing UPMC’s two-year bundling pi­lot led to length-of-stay re­duc­tions for hips and knees of 9% and 5%, re­spec­tively, and to­tal cost sav­ings of about 2%, Min­nier said.

Ho­gan is now mak­ing reg­u­lar “road trips” to UPMC’s re­gional part­ners that want to learn how to suc­ceed with bun­dled pay­ment. “It’s a joy to work on an in­no­va­tion like this,” he said.

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