56% of Ortho Programs “Unprepared” for Bundled Payments! // Joint Replacement: Big Differences in Academic, Community Hospitals // and More!

56% of Ortho Programs “Unprepared” for Bundled Payments!

A new survey from Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) and Wellbe, Inc. has found that more than half of the orthopedic programs in the U.S. are not ready for the onslaught on bundled payments. Less than 10% of programs reported being “fully” prepared.

David Ayers, M.D. is chair of the Department of Orthopedics and Physical Rehabilitation at UMass Medical School. As co-lead of FORCE-TJR, Dr. Ayers guides this program of national benchmarking that provides an assessment of a hospital/surgeon practice readiness for the bundled payment initiative—and gives information on the exposure to factors that drive the cost and quality score.

Dr. Ayers told OTW, “The biggest issue for the typical hospital is that they do not know how they compare to other hospitals in the region. They do not know how their Medicare patients compare with regards to their clinical risk factors such as body mass index, age, Charlson co-morbidity index, smoking history and the other clinical factors that put patients at higher risk for complications and readmission. Complications and readmission are very costly and will greatly affect a hospital’s performance in the Comprehensive Care for Joint Replacement (CJR) Model. Hospitals have requested that FORCE-TJR do a diagnostic evaluation of their Medicare patients’ risk factors and how they compare to the FORCE-TJR national norms.”

“The most misunderstood aspect is that most hospitals have no knowledge of events such as readmission or ER visits that occur at other institutions during the bundle period. But the original hospital where the TJR took place still is financially responsible for the admission and the costs are in the bundle.”

“Surgeons should be aware that their electronic medical record (EMR) is not the answer to managing patients in a bundled payment program like CJR. The EMR is hospital centric and does not follow the patient through the entire episode and typically misses major post-discharge events that greatly affect their performance in the bundled payment program. Surgeons should also be planning how to implement PROM (Patient Reported Outcome Measures) data collection in their practice. Data collection particularly post-discharge data collection is challenging and the system used should be patient centric and be able to provide national norms and risk adjusted results and have a proven track record of success in achieving high post-op PROM completion rates.”

Joint Replacement: Big Differences in Academic, Community Hospitals

A team of researchers from Cleveland Clinic is stepping up to fill in a gap in the joint replacement literature. With little information available on total hip arthroplasties (THA) that are done in community hospitals, Carlos A. Higuera Rueda, M.D., an orthopedic surgeon at Cleveland Clinic in Ohio, worked with his team to get answers. One thing they learned was that academic hospitals had lower total cost per procedure, while community hospitals had a shorter mean length of stay. He told OTW, “We wanted to characterize better the risk profile for in-hospital adverse outcomes after THA of academic vs. community hospitals. This may aid in assessing risk for new alternative payment programs such as bundled payments at these hospitals.”

“It was surprising to see that there is a difference in risk, however it is not as we initially expected. Initially, we thought that after adjustments of comorbidities, the complications were going to be lower in the academic hospitals. We learned that the risk of some severe complications such as shock, upper respiratory complications and respiratory insufficiency is higher in community hospitals. However, the risk of thromboembolism, pulmonary embolism and vascular complications is higher in academic ones.”

“Similar studies have been done using different data sources and at different levels such as Medicare data or single institution’s data, mainly to assess mortality, infections and readmissions. However, these outcomes are not as common as other in-hospital complications and are not comprehensive enough to give all the potential risk profile of this procedure in different types of hospitals.”

Asked if he were to redo the study, would he do anything different, Dr. Higuera Rueda commented to OTW, “I would like to have more detailed and accurate data including details related with the surgical procedure such as approach, length of surgery, severity of the index procedure, etc. And then, use that data as part of the adjustment when assessing odds ratios.”

Knee Replacement: High-Volume Hospitals Would Save $2.5-$4 Billion!

New work from Hospital for Special Surgery (HSS) has found that if everyone needing a knee replacement underwent the procedure at a high-volume hospital, it would result in a savings of between $2.5 and $4 billion annually by the year 2030. Low volume were those performing less than 90 total knee replacements per year, medium volume performed 90-235 per year, high volume centers did 236-644, and very high volume handled 645 or more total knee replacements per year.

Jayme Burket, Ph.D. was the lead study author. She told OTW, “There are a number of policy initiatives that could be implemented. One strategy that has been proposed is the implementation of minimum volume standards for reimbursement and/or participation in bundled payment programs. I think what is even more important is to gain a better understanding of why exactly higher volume hospitals perform better. Is it that practice makes perfect and by doing a lot of these procedures they are getting really good at them? Or, are there processes of care taking place at these centers that are resulting in better outcomes, such as the appropriate selection of patients, appropriate use of surgery and surgical technologies, standardization of care pathways, and integrated perioperative care? If we figure out the mechanisms, then we can potentially disseminate this information to lower volume and underperforming centers and help them raise their standards.”

“Some lower volume hospitals play an important role in providing access to care and we must take this and patient preferences into account. The answer here is definitely not to deny access or close all lower volume hospitals—that would be neither feasible nor ethical. However, policy initiatives to educate and incentivize patients to go to higher volume centers when the option is available are a viable option, especially given that a substantial proportion of low volume hospitals are not located in rural areas as one might think, but rather in and around hospital-dense metropolitan areas where there are higher volume centers available.”

“In the end, volume metrics are a surrogate for what we really want to measure, which is quality. This means measuring factors that are the drivers of patients’ decision to undergo surgery in the first place, such as function, pain, and quality of life. Unfortunately, these are quite challenging to measure in clinical practice, and we have quite a ways to go before we can do this reliably. In the meantime, a multi-faceted approach helping to guide patients to higher volume options when available, combined with education and the dissemination of successful care practices from high volume hospitals, are reasonable strategies that can be implemented to improve patient outcomes and potentially reduce the financial burden of knee replacement.”