Bun­dled-pay­ment joint re­place­ment pro­grams win­ning over sur­geons

Modern Healthcare - - NEWS - By Har­ris Meyer

When ad­min­is­tra­tor Dr. Ge­of­frey Cole found out last year that his hos­pi­tal would be par­tic­i­pat­ing in Medi­care’s manda­tory bun­dled-pay­ment pro­gram for to­tal hip and knee re­place­ment pro­ce­dures, he started meet­ing with or­tho­pe­dic sur­geons.

Cole ini­tially was skep­ti­cal about the Com­pre­hen­sive Care for Joint Re­place­ment, or CJR, pro­gram the CMS In­no­va­tion Cen­ter launched in April 2016. “We would not have cho­sen to be in this pro­gram un­less it was man­dated, but we ac­cepted it and dealt with it,” said Cole, vice pres­i­dent of an­cil­lary ser­vices at Pied­mont Athens (Ga.) Re­gional Med­i­cal Cen­ter.

But he quickly en­gaged physi­cians in the process of re­design­ing and im­prov­ing the pa­tient-care process—ex­actly what ex­perts say is key to the suc­cess of bundling and other value-based pay­ment ini­tia­tives. Close ties be­tween pay­ment and clin­i­cal care are mak­ing it crit­i­cal for physi­cians to be cen­trally in­volved in these ef­forts.

“One of the nice things about bun­dled pay­ment is it can pro­vide a direct fi­nan­cial re­ward for physi­cians to work hard on as­pects of care that can be dif­fi­cult and re­quire co­or­di­na­tion with the hos­pi­tal,” said Dr. Amol Na­vathe, an as­sis­tant pro­fes­sor of health pol­icy and medicine at the Univer­sity of Penn­syl­va­nia. “It’s im­por­tant that physi­cians be en­gaged and bought in.”

In a study pub­lished in Fe­bru­ary in JAMA In­ter­nal Medicine, Na­vathe and his co-au­thors found that vol­un­tary Medi­care bun­dled-pay­ment pro­grams for joint re­place­ments at Bap­tist Health Sys­tem in San An­to­nio re­sulted in a 21% drop in av­er­age Medi­care episode spend­ing be­tween 2008 and 2015. Read­mis­sions, emer­gency depart­ment vis­its, and cases with pro­longed lengths of stay all de­clined sig­nif­i­cantly.

Par­tic­u­larly no­table was that costs for joint im­plant de­vices fell 29% as a re­sult of sur­geons col­lab­o­rat­ing with the hos­pi­tal to ne­go­ti­ate lower prices. In ad­di­tion, costs for post-sur­gi­cal stays in re­ha­bil­i­ta­tion fa­cil­i­ties and skilled-nursing fa­cil­i­ties dropped by 49% and 33%, re­spec­tively. That was an­other re­sult of physi­cians fo­cus­ing on fine-tun­ing the en­tire episode of care.

While many hospitals and physi­cian groups are work­ing on im­prov­ing care out­side the CMS’ bun­dled-pay­ment pro­grams, the fi­nan­cial in­cen­tive of meet­ing a fixed cost tar­get for an en­tire episode of care has spurred a stronger col­lab­o­ra­tion be­tween these of­ten-com­pet­ing play­ers. That’s true even for hospitals and med­i­cal groups that have not es­tab­lished fi­nan­cial ar­range­ments in which doc­tors get bonuses for meet­ing cost tar­gets, known as gain-shar­ing.

Be­fore, “the com­pet­ing in­ter­ests had no in­cen­tive to sit at the ta­ble and take out in­ef­fi­cien­cies,” said Dr. Henry Sul­li­vant, vice pres­i­dent and chief med­i­cal of­fi­cer for Mem­phis, Tenn.-based Bap­tist Memo­rial Health Care Corp. “The won­der­ful thing about this type of pro­gram is it puts us all at the ta­ble to­gether solv­ing is­sues col­lab­o­ra­tively.”

Bap­tist Memo­rial has hospitals par­tic­i­pat­ing in both the CMS’ vol­un­tary and manda­tory pro­grams; the vol­un­tary pro­gram is called Bun­dled Pay­ments for Care Im­prove­ment, or BPCI. It ne­go­ti­ated a gain-shar­ing deal with two in­de­pen­dent groups of or­tho­pe­dic sur­geons.

Now, how­ever, some ex­perts fear HHS’ re­cent de­ci­sion to shrink the CJR pro­gram to 34 from 67 mar­kets and shelve plans for two manda­tory bun­dled-pay­ment pro­grams for car­diac care may slow such col­lab­o­ra­tions.

They say the fi­nan­cial rewards to physi­cians for re­duc­ing costs and im­prov­ing qual­ity for en­tire episodes of care—which can amount to a 50% bonus in the BPCI pro­gram—are strong mo­ti­va­tors to get them en­gaged. They hope that HHS and the CMS at least main­tain and ex­pand vol­un­tary bun­dled-pay­ment ini­tia­tives.

“I do worry if we dial back these pro­grams and don’t re­place them with ad­di­tional pro­grams, we could lose a lot of mo­men­tum we’ve never seen be­fore in trans­form­ing care,” Na­vathe said.

But Na­vathe and oth­ers say BPCI and other vol­un­tary value-based pay­ment pro­grams can con­tinue to sup­port those trans­for­ma­tions. In­deed, some hospitals and physi­cian groups say the BPCI pro­gram’s qual­ity mea­sure­ments are more use­ful for providers than what the CJR pro­gram of­fers, though they ar­gue that BPCI’s fi­nan­cial in­cen­tive model needs to be re­vised to bet­ter re­ward low-cost providers.

“These pro­grams are forc­ing physi­cians to look holis­ti­cally at the pa­tient for an en­tire episode,” said Andy Tessier, di­rec­tor of busi­ness de­vel­op­ment for the Sig­na­ture Med­i­cal Group, which con­sults with about 1,200 or­tho­pe­dic sur­geons around the coun­try par­tic­i­pat­ing in the BPCI demo pro­gram. “What I’m hear­ing is they are mak­ing these spe­cial­ists bet­ter doc­tors.”

At Pied­mont Athens, Cole and sur­geons from two lo­cal or­tho­pe­dic groups started by study­ing their uti­liza­tion and cost data. They quickly no­ticed that about half the joint re­place­ment pa­tients in the three prior years went to re­ha­bil­i­ta­tion or skilled-nursing fa­cil­i­ties af­ter surgery. That was ex­pen­sive and did not nec­es­sar­ily pro­duce the best out­comes. Plus, it could ham­per the hos­pi­tal’s abil­ity to pro­vide the pro­ce­dure and care for up to 90 days af­ter­ward for Medi­care’s bun­dled tar­get price.

So the sur­geons be­gan coach­ing their pa­tients to ex­pect to go di­rectly home af­ter surgery. They worked hard on min­i­miz­ing re­fer­rals to re­hab and SNFs and send­ing pa­tients home, with phys­i­cal ther­apy and other home health ser­vices as needed. Cole and the sur­geons also de­cided Pied­mont Athens needed to ap­point a nurse to serve as CJR co­or­di­na­tor to work with pa­tients and their fam­i­lies be­fore, dur­ing and af­ter the pro­ce­dure.

As a re­sult, af­ter the bun­dled-pay­ment pro­gram started April 1, 2016, use of post-acute fa­cil­i­ties for Pied­mont Athens’ joint re­place­ment pa­tients al­most im­me­di­ately plum­meted from about 50% of cases to about 10%.

The sur­geons liked that pa­tient out­comes were bet­ter and costs were lower un­der the new pro­gram, Cole said. The hos­pi­tal re­cently re­ceived a $107,000 bonus from Medi­care for meet­ing the CJR pro­gram’s cost and qual­ity tar­gets. It has de- cided to con­tinue in the bun­dled-pay­ment pro­gram next year, even though HHS is propos­ing to make it vol­un­tary for hospitals in the Athens mar­ket.

Cole said the sur­geons have been en­gaged and co­op­er­a­tive, and they’re bring­ing more of their joint re­place­ment pro­ce­dures to Pied­mont Athens since the bun­dled-pay­ment pro­gram started. “Two years ago I would have said no more (manda­tory) bun­dles,” he said. “I might say yes to that now.”

Like him, ad­min­is­tra­tors and physi­cians in­volved in the CMS’ manda­tory and vol­un­tary bun­dled-pay­ment ini­tia­tives at other hospitals say they’re im­pressed with how the pro­grams have en­gaged physi­cians to pro­duce lower costs and bet­ter out­comes for pa­tients. They see po­ten­tial for achiev­ing sim­i­lar re­sults through bun­dled pay­ment in other clin­i­cal ar­eas.

In­deed, based on its suc­cess with the joint re­place­ment bun­dles, Bap­tist Health in San An­to­nio ex­panded to of­fer bun­dles for col­orec­tal surgery, acute my­ocar­dial in­farc­tion, and sev­eral other pro­ce­dures and con­di­tions.

“This has ex­panded to other clin­i­cal ar­eas, and we’ve con­tin­ued to de­velop care paths,” said Mon­ica Dead­wiler, se­nior di­rec­tor of fi­nan­cial prod­uct in­no­va­tion at the Cleve­land Clinic, whose hospitals are par­tic­i­pat­ing in the BPCI pro­gram for joint re­place­ments.

She be­lieves, how­ever, that bun­dled pay­ment is best suited for pro­ce­dural care, where there is a de­fined be­gin­ning and end to the episode, than for chronic dis­ease man­age­ment.

Se­lect­ing the right physi­cian lead­ers is crit­i­cal to suc­cess in en­gag­ing doc­tors in re­design­ing care path­ways for bun­dled pay­ment, Dead­wiler said. At the Cleve­land Clinic, the first pri­or­ity was been to iden­tify and get the buy-in of a physi­cian leader to head the roll­out.

Cleve­land Clinic started work­ing in 2011 on its BPCI pro­gram for joint re­place­ment at Euclid Hos­pi­tal, where the care re­design ef­fort was led by the physi­cian who was the hos­pi­tal’s pres­i­dent. Af­ter the Euclid model went live in 2013, the Cleve­land Clinic ad­justed it, doc­u­mented the model in a “play­book,” then en­gaged physi­cian lead­ers at its other hospitals to tai­lor the re­design for those sites.

At each hos­pi­tal, the physi­cian leader con­vened a kick­off meet­ing with the doc­tors and other clin­i­cal staff in­volved in joint re­place­ments to dis­cuss how to stream­line the pre-sur­gi­cal, in­pa­tient and post-acute pro­cesses and de­ter­mine what re­sources were needed to achieve that. That was fol­lowed by mul­ti­ple meet­ings to de­sign and test the new model and of­fer any sup­port physi­cians needed in their of­fices.

Use of data is cen­tral in en­gag­ing physi­cians in bun­dled-pay­ment pro­grams, the groups say. Sig­na­ture Med­i­cal’s Tessier said the sur­geons with whom his group con­sults around the coun­try had never seen de­tailed post-acute uti­liza­tion and spend­ing data be­fore. They typ­i­cally knew lit­tle about what hap­pened with their pa­tients af­ter surgery.

That’s why the data on where their pa­tients went af­ter surgery and the rate of ad­verse out­comes gen­er­ated by post-acute uti­liza­tion was “eye-open­ing” to them, he said.

“It’s a process of get­ting the doc­tors in a room and look­ing at the data to­gether,” Tessier said. “It’s not telling the doc­tors what to do. It’s be­ing the mod­er­a­tor so they can make ev­i­dence-based changes to their prac­tice.” The physi­cians some­times use the data to call out col­leagues who are out­liers, he added.

An­other key to the suc­cess of bun­dled pay­ment is help­ing sur­geons pre­pare pa­tients and their fam­i­lies for the surgery and re­cov­ery phases. That in­cludes work­ing with pa­tients to im­prove their health be­fore surgery to op­ti­mize out­comes, such as en­cour­ag­ing them to lose weight or quit smok­ing. Many or­tho­pe­dic groups have in­vested in hir­ing nurse prac­ti­tion­ers or sur­gi­cal as­sis­tants to do this pa­tient ed­u­ca­tion work.

“It takes more time and I barely break even, but I’m ex­tremely proud of our pro­gram be­cause the qual­ity of care is awe­some, and we’re de­creas­ing over­all costs to Medi­care,” said Dr. Matthew Weresh, whose group, DMOS Orthopaedic Sur­geons in Des Moines, Iowa, par­tic­i­pates in the BPCI pro­gram. “Pa­tients are hap­pier, and they’re re­cov­er­ing quicker.”

Some of his part­ners, how­ever, aren’t tak­ing as much time with pa­tients as oth­ers are, he said. So his group puts pres­sure on them be­cause the group as a whole only re­ceives a gain-shar­ing bonus if it meets its over­all cost and per­for­mance tar­gets.

CHI St. Alex­ius Health in Bis­marck, N.D., saw bun­dled pay­ment com­ing and started work­ing in­ten­sively with its sur­geons on a care-im­prove­ment process sev­eral years ago. So it was well-pre­pared when it found it­self drafted into Medi­care’s manda­tory CJR pro­gram last year.

St. Alex­ius’ col­lab­o­ra­tion fea­tures a close “dyad” part­ner­ship be­tween Raumi Ku­drna, a nurse who di­rects the hos­pi­tal’s to­tal joint pro­gram, and or­tho­pe­dic sur­geon Dr. Dun­can Ack­er­man, who serves as the con­duit to the other sur­geons. They have as­sem­bled im­promptu teams to de­sign rapid so­lu­tions for in­creas­ing same-day dis­charges af­ter surgery and im­prov­ing pain man­age­ment.

Now HHS has pro­posed to make bun­dled pay­ment for joint re­place­ments op­tional in the Bis­marck area. CHI lead­ers are wait­ing to see how St. Alex­ius and other CHI hospitals fared fi­nan­cially on the CJR pro­gram in 2016 be­fore de­cid­ing whether to stay in.

Ku­drna doesn’t know what the de­ci­sion will be, but she’s sure the col­lab­o­ra­tion to im­prove care and re­duce costs will con­tinue. “We put a lot of things in place that seem to work for our pa­tients,” she said. “I don’t see any of that chang­ing, whether we opt in or out.”

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.