Becker's Hospital Review

26 Bundling for the Best: Notes From the Field on Bundled Payment Design and Implementation T hough hip and knee replacements are among the most common surgeries for Medicare beneficiaries, the quality and cost of care for these surgeries vary immensely between providers. Medicare spends an average range of $16,500 to $33,000 for surgery, hospitalization and recovery, and rates can vary more than three-fold for complications such as infections or implant failures, according to CMS. Bundled payments are one way to reign in the cost and quality of care for inpatient primary procedures. In July, CMS proposed a five-year Comprehensive Care for Joint Replace- ment payment model that would mandate participation in bundles for hip and knee replacements across 75 geographic areas. On the heels of this proposal, we checked in with three healthcare leaders with experience in bundled payments to identify strategies for designing, implementing and driving care redesign through this payment innovation. Participants include: Denise A. McGinley, MSNAd, RN, Director, Center for Ortho- paedic Innovation, St. Luke's Medical Center in Phoenix. About three years ago, St. Luke's Center for Orthopaedic Innovation decided to participate in the Bundled Payments for Care Improvement Initiative for hip and knee replacements, one of CMS' Innovation Center programs. At this point, Ms. McGinley says the hospital plans to exclusively use bundles in ortho- pedics, but it has discussed the possibility of expanding the model to other service lines, like its open heart program. Steven F. Schutzer, MD, Medical Director, Connecticut Joint Replacement Institute, President, Connecticut Joint Replace- ment Surgeons, LLC. In 2009, Hartford, Conn.-based Saint Fran- cis Hospital & Medical Center and Woodland Anesthesia group began discussing the value of bundled payments. As early adopters, in 2010 the organizations launched a commercial bundled payment initiative for primary total knee and primary total hip replacements. Michael Kelly, MD, Chairman, Department of Orthopaedic Sur- gery and Sports Medicine, Chairman, Department of Physical Medicine and Rehab, Hackensack (N.J.) University Medical Center. Hackensack UMC began participating in January 2013 in the Bundled Payments for Care Improvement Initiative. Since then, the experience has illuminated the costs associated with the post-acute experience and enabled the those in the pro- gram to make changes to the way they deliver care and work with other provider partners across the entire care continuum. Note: Responses have been edited lightly for length and style. Question: What are some best practices you use to implement and execute bundled payment programs? Denise McGinley: There are several best practices we use. First, bundles make data available [that] we've never had before. One best practice is to look at this data on a regular basis and sort out reasons for readmissions and delays in progress. If it can't be found through the data, we contact patients to find out exactly what happened, then implement performance improvements to cut down on future readmissions and delays in progress. Second, we use all micro-invasive surgical approaches unless there is a reason to take a more extensive approach. Virtually no muscle is cut. That means all of our patients go home within 24 hours relatively pain free. They no longer need patient-controlled analgesics and need only limited narcotics, so they are able to ambulate early and often. They don't need skilled nursing facilities or inpatient rehabilitation, which is an enormous post-surgical cost. We have been able to reduce post-acute readmissions to less than 15 percent. The focus of our bundles has been optimizing anesthesia practices, utilizing cutting edge surgical approaches and looking at where we spend our money on the inside of our hospital to prevent costs on the outside. Dr. Steven Schutzer: In 2006, the surgeons that started the Connecticut Joint Replacement Institute, (the Connecticut Joint Replacement Surgeons), agreed to two overarching principles. First [they agreed] to make data-driven decisions and, second, to adopt a standardized model of care delivery. This marked the beginning of our value journey. For surgeons, however, the concept of standardization connotes a 'we-tell-you-what- to-do' approach. That will not work. Instead, we work together as a group to discuss ideas and then vote on clinical protocols. We prefer to call these consensus-based protocols rather than standardized or evidence-based best practices. We now have 16 protocols. A prime example of one is our transfusion protocol. In 2011, our data showed our transfusion rate was 21 percent for primary joint arthroplasties. Our conclu- sion was that this was excessive, so we explored opportunities and decided to implement a blood conservation protocol. Six months later, the transfusion rate was 4 percent. We use the Deming Cycle — Plan, Do, Check, Act — as part of our iterative quality improvement process. Two years ago, with the addition of Tranexamic Acid, we further reduced transfusion rates to 1.5 percent. Dr. Michael Kelly: One of the most critical times to focus on is preoperatively. We found many of our patients expected to begin rehab after they left the hospital in a rehab facility, rather than begin while they were in the hospital. They weren't prepared for the possibility they may go home, nor did they have appropriate expectations for the procedure. They were influenced by their peers and relatives. We found it was critical to focus on the pre-operative touchpoints and truly educate our patients. Then, we needed to tighten up our protocols and stan- dardize across all of our total joint physicians. We have had a significant focus on pre-operative education to align patient and surgeon expectations. The hospital provided additional resources to add a joint program nurse navigator and two advanced practice nurses. They are actively involved in each step of the patient experience. Both patients and nurses have found this pre-operative education program has had a pro- foundly positive effect on our patients' experience. It allowed us to consistently deliver on what we were discussing with the patients preoperatively, rather than have variability from one provider to another. 26 Executive Roundtable: Bundling for the Best

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