NYU Langone Medical Center’s TJA BPCI Experience: Lessons in How to Maximize Value
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The Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January of 2013. Dr. Iorio will outline the challenges and benefits of implementing BPCI for Total Joint Arthroplasty at an urban, tertiary, academic medical center with a hybrid compensation model. Early results from the implementation of a Medicare BPCI Model 2 primary TJA program demonstrate cost-savings with an improvement in quality of care metrics and continued cost savings through year 3 of our experience. Changes in patient optimization, care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the Bundled Payment for Care Initiative, thus bringing increased value to our TJA patients.
Maximizing Value in a Bundled Environment – Keys to Success:
• Evidence based, cost effectiveness analysis
• Standardized protocol adoption
• Transparent data
• Perioperative Patient Optimization
• Care management
• Physician-hospital alignment with Gain sharing
• Enhanced pain relief and rehabilitation protocols
• Blood management and rational VTED prophylaxis
About the Speaker:
Richard Iorio, MD, is the William and Susan Jaffe Professor of Orthopaedic Surgery at New York University Langone Medical Center Hospital for Joint Diseases and Chief of Adult Reconstruction at NYU Langone HJD. He co-founded Labrador Healthcare Consulting Services, Responsive Risk Solutions, and the Value Based Healthcare Consortium in 2015. He is a member of the Board of Directors for LIMA, the Lifetime Initiative for the Management of Arthritis. Dr. Iorio is a national expert in physician and hospital quality and safety and a leader in the implementation of alternate payment paradigms in orthopaedic surgery.
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More Related Content
NYU Langone Medical Center’s TJA BPCI Experience: Lessons in How to Maximize Value
1. NYULMC Hospital for Joint Diseases
NYU Langone Medical Center’s TJA BPCI
Experience: Lessons in How to Maximize Value
Richard Iorio, MD
Chief of Adult Reconstruction
William and Susan Jaffe Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
NYU Langone Medical Center
Hospital for Joint Diseases
2. Disclosures
• Consultant for Medtronic and DJO Surgical
• Product liability consultant for DePuy Orthopaedics
• Co-founder Labrador Healthcare Consulting Services
• Co-founder LIMA Project
• Co-founder Responsive Risk Solutions
• Advisory Board Member Pacira, Wellbe, Inc, ActiveCare MCS, Muvehealth
• AAHKS, Knee Society and Hip Society Member
• Consultant reviewer for JBJS, CORR, JOA, JAAOS
• Editorial Board JBJS Reviews, Adult Reconstruction Section Editor
• Institutional Research Support: Pacira, Orthofix, Vericel, Orthosensor,
Bioventus, Ferring
2
3. The Future is Here
Value Based Purchasing (VBP)
•The goal of value based purchasing (VBP) is to transform Medicare
from a passive payer of claims to an active purchaser of care.
•In the past health care organizations were profitable as long as they
processed patients.
•For decades, health care systems have responded to incentives that
rewarded volume regardless of quality.
•VBP is an effort to change the focus of how care is paid for: in essence,
the government wants value – not just quantity – for the money that it
spends.
•Episode of care delivery such as bundled payment offers a framework
to measure the amount of value brought to a diagnosis
3
4. Bundled Payment Initiative
Background
•NYULMC HJD is a large, tertiary, academic medical center with a hybrid
compensation system which implemented a Model 2 bundled payment
initiative for Total Joint Replacement, Spinal Fusion and Cardiac Valve
Surgery in January of 2013.
•In April of 2016, CJR, a modification of Model 2 BPCI, was instituted in
67 MSA’s by CMS
•In January of 2017, quality and financial metrics will begin collection for
MIPS under MACRA which will regulate CMS reimbursement for the
foreseeable future as a replacement for SGR adjustments
•In January of 2018, voluntary participation in BPCI and CJR will be
reopened to allow for advanced APM fulfillment of the requirements of
MIPS and MACRA
4
5. The Future is Here
Differences between BPCI and CJR
•All episodes will be 90 days of care (Model 2 BPCI)
•No third party purveyors or EI, hospitals only
•Historical and Regional data is used to set target price in years 1-3
•Regional data only will be used for year 4 and 5 in CJR
•Quality metric reporting and PRO measurement will be rewarded
•Hospital Quality Standards will be used to determine eligibility for
reconciliation: RSCR, HCAHPS, and PROMs
•Reconciliation will be awarded with a composite score methodology of
quality measures and financial performance
•No physician risk throughout the program, No hospital risk in year 1
•Stop loss limits, 5% above target in year 2, 10% in 3, and 20% in years 4-5
•Gains limited to 20% above target price x number of episodes
•Risk stratified episode threshold for hip fractures
•Relief for difficult diagnoses like HCV, HIV and Hemophilia
5
6. CJR
It’s good to be bad…until it’s not
• CMS recognizes that hospitals may have limited ability to moderate spending
for certain high cost cases. Therefore in setting target prices for both MS-DRGs,
CMS proposes to set a high outlier limit at two standard deviations above the
regional average episode cost. Individual episode costs that exceed the high
outlier limit would be truncated to that limit so hospitals’ downside risk would be
limited.
• CMS does not propose to set target prices based solely on historical hospital-
specific data but rather intends to use a blend of historical hospital-specific and
regional-historical claim data. CMS proposes to transition to using regional only
data to set targets by PY 4. CMS asserts this approach will afford early and
continuing incentives for both efficient and less efficient hospitals to furnish high
quality, efficient care in all years of the model.
• CMS recognizes the need for more physician involvement and will rectify this in
January 2018 with the ability of physicians to take more risk in both models
6
7. The Future is Here
There will be winners and losers within the CJR demonstration project
7
Years 1 and 2 Year 3 Years 4 and 5
100%
Regional2/3
Regional
1/3
Hospital
1/3
Regional
2/3
Hospital
Target price based on hospital (historical) and regional pricing
8. Bundled Payment Initiative
Background of BPCI
•The episode of care included the inpatient and post-acute care and all
costs through 90 days following discharge. The patient does not
receive financial incentives. CMS requires quality measure reporting. A
provider’s participation may be terminated by CMS if quality decreases
or if CMS identifies a significant concern.
•All unilateral, primary TKA and THA were included. Revisions and
bilateral TJA were excluded. DRG’s 469 and 470 were included and
payment was increased for DRG 469 due to the increased
comorbidities. The reference years for cost comparison were 2009-12.
•Clinical care coordination among all providers, evidence based clinical
pathway implementation, and standardization of post discharge care
were critical to the success of the program.
8
9. What is Included in the Target Price?
Home Health
Agencies
Outpatient
Therapy Services
Skilled Nursing
Facilities & LTACH
Inpatient Rehab
Hospital
Surgeon
Physician Visits
(surgeon and other)
Any services during the 90-Day
Post-Acute Period
such as…
Consulting
Physicians
Readmissions
(to NYU or others)
DME
9
Part B Drugs Outpatient Services
Lab Services
Anesthesiologist
Any
services
during the
Acute Stay
such as…
Any services
72 hours
prior to
Admission
such as…
ED Visits
Physician Visits
(surgeon and other)
PAT
Days 91-120
CMS will be
monitoring the period
immediately following
to ensure that
services are not
being shifted outside
the bundle.
NYULMC will be
financially
responsible if such
behavior is observed
and may be removed
from the program.
10. Avg Medicare Payment1
DRG DRG Description Inpatient Only2 90D Bundle3
469 MAJOR JOINT REPLACEMENT W MCC $16,303 $54,233
470 MAJOR JOINT REPLACEMENT W/O MCC $12,446 $35,565
1Data is based on FY 2009-12 Medicare claims. CMS will be carrying rates forward to 2013 for the Episodes of Care Initiative.
2Inpatient payment includes patient deductible/coinsurance amounts, and excludes IME, DSH, Capital, and GDME payments.
390D Bundle includes Medicare readmissions exclusions and Part B services exclusions, updated as of January 9th, 2013
2009 Medicare Payments - Inpatient Stay and 90 Day Bundle
Primary Joint Replacement (MS-DRGs 469-470)
10
11. Any patient having surgery at pilot
hospital for one of the MS-DRGs is
by default a part of the bundle;
It is not physician-specific
How Does Retrospective Bundling Work?
Claim from hospital
triggers a bundle
Patient is flagged by
CMS
CMS pays all providers
as normal
All providers bill Medicare
as normal
Retrospectively the sum
of claims is reconciled
against the target price
If it is LOWER than the target,
the awardee will receive a check
for the difference
If it is HIGHER than the target, the
awardee has to repay CMS
11
12. 12
All post-acute Medicare costs incurred within the 90d bundle are categorized by the initial post-acute setting
(i.e., includes readmissions and other levels of care following the initial setting)
Relative Cost of 90 day Episodes of
Care by Post-Acute Setting
3-Yr Baseline Period
14. Reporting and Monitoring
•Bundled Payment Weekly Dashboard – example of physician
scorecard
Confidential. Do Not Distribute. 14
Discharge Disposition
90-Day Readmission Rate - Closed
Episodes Only1
# Patients
Discharged
ALOS Rehab
Facility
SNF Total
Facility-
Based
Care
HHA Home/
Self Care
Total
Home-
Based
Care
#
Readmissions
# Patients 90-Day
Readmission
Rate
Primary Joint of the Lower
Extremity 865 3.51 6% 37% 43% 54% 3% 57% 42 338 12%
HJD 813 3.41 6% 34% 40% 57% 3% 60% 35 317 11%
DRG 469 - Primary Joint w
MCC 19 6.84 21% 32% 53% 42% 5% 47% 1 2 50%
Physician A 4 6.00 25% 50% 75% 25% 0% 25% 0 0 0%
Physician B 4 8.75 25% 25% 50% 50% 0% 50% 0 0 0%
Physician C 2 5.47 0% 50% 50% 0% 50% 50% 0 0 0%
Physician D 2 4.50 0% 50% 50% 50% 0% 50% 0 0 0%
Physician E 2 6.63 100% 0% 100% 0% 0% 0% 0 0 0%
Physician F 2 9.35 0% 50% 50% 50% 0% 50% 0 1 0%
Physician G 1 3.00 0% 0% 0% 100% 0% 100% 0 0 0%
Physician H 1 13.00 0% 0% 0% 100% 0% 100% 0 0 0%
Physician I 1 3.00 0% 0% 0% 100% 0% 100% 1 1 100%
15. 15
Episodes of Care Initiative
Ways to Improve Quality and Efficiency
• Reduce readmissions
• Reduce LOS
• Reduce implant, supply, or drug costs
• Reduce OR time
• Alter discharge patterns to more cost-efficient settings
• Decrease excess utilization (e.g., consults ancillary tests)
• Optimize patient health preoperatively
• Optimize patient education, care management, pain
management, blood management, VTED management and
patient expectations
Quality improvements and efficiencies will benefit all patients, regardless of payer.
16. Clinical Management Throughout the Pathway
16
The Importance of Care Coordination
• Enforces best practices / standardization of pathways, workflows, and order sets
• Improves communication between providers and to the patient
• Ensures follow-up after care transitions
• Optimizes Patient Education, Expectations and Outcomes
17. Bundled Payment Initiative
BPCI Results Y1
• 721 patients were available for analysis at the time at the end of year one.
• Average of length of stay was decreased to 3.58 days from 4.27 days (Median
LOS 3 days).
• Discharge to inpatient facilities has decreased on average from 63% to 44% on
average, and 38% for the last month.
• Readmissions occurred in 80 of 721 patients, 7% of patients at 30 days, 11% at
60 days and 13% at 90 days which is slightly less than prior to BCPI (17% in
2011, 15% in 2009).
• The hospital realized significant cost reduction in the inpatient component year
over year. We have achieved positive margins vs. CMS target price in the first
three years without accounting for the costs of implementation. We have
maintained these margins since the at risk period began in Oct. 2013.
17
20. Bundled Payment Initiative
20
BPCI Y1 Results
•DRG 470: Primary TJA of the Lower Extremity w/o MCC,
17% savings vs. target for Q1 and Q2 reconciliation
•For DRG 469: Primary TJA of the Lower Extremity with MCC,
8.1% savings vs. target for Q1 and Q2 reconciliation
21. Bundled Payment Initiative
Conclusions
• We decreased length of stay
• We decreased discharges to inpatient facilities
• We decreased the cost of the episode of care
• We had not significantly altered the readmission rates, but had begun to make inroads
• We have implemented a surgeon directed risk factor stratification and modification
program to delay surgery in those high risk patients which represent the most likely
patients to have complications:
1. Morbid Obesity
2. Uncontrolled Diabetes and poor nutrition
3. Smoking cessation
4. Neurocognitive and Dependency issues
5. VTED
6. Physical deconditioning and Fall Risk
7. Infection prevention, Staph Colonization and Hepatitis C
8. Cardiovascular and Stroke complication prevention
• In addition to patient optimization, the introduction of EBM based blood, pain and care
management protocols were accomplished
21
22. Preventing Hospital Readmissions and Limiting the
Complications Associated with Total Joint Arthroplasty
Comorbidity Prevalence in NYULMC HJD
TJA patients
•Musculoskeletal comorbidities 73.8%
•Hypertension 60.1%
•Hyperlipidemia 55.3%
•Tobacco use 22.0%
•Diabetes 19.2%
•Depressive disorders 14.5%
•Ischemic Heart Disease 13.5%
•Morbid Obesity 13.8%
•Dysrhythmias 10.8%
•Valve disease 7.8%
•Cerebrovascular Disease 4.4%
•CHF 2.8%
22
23. Preventing Hospital Readmissions and Limiting the
Complications Associated with Total Joint Arthroplasty
23
Severity of Risk Factors Correlates with Financial Risk of Readmission
24. Preventing Readmissions
Modifiable Risk Factors
• MRSA Screening and Decolonization, weight based antibiotic dosing, and use of Vancomycin and Gentamycin in
high risk patients, Hepatitis C screening and treatment
• Smoking cessation (hard stop)
• Cardiovascular Optimization and Stroke Prevention (using PT, High dose Statins, and ACE inhibitors
perioperatively)
• Aggressive weight control (hard stop at a BMI of 40)
• Catastrophizing avoidance, interventions for depression
• Drug and alcohol interventions
• Fall education prevention
• Physical deconditioning and frailty improvement interventions
• Diabetes control and nutritional interventions for malnutrition (Hard Stop with glucose > 180)
• Screening for high risk VTED patients with testing for thrombophyllia risk
• Risk adjusted VTED prophylaxis, use ASA and SPCD’s with standard risk patients, avoid aggressive
anticoagulation
24
30. Five Pillars of Bundled Payment Success
30
Optimize patient selection and comorbidities
Optimize care coordination/patient education/expectations
Use a multimodal pain management protocol, minimize
narcotics
VTED risk standardization and optimized blood
management
Minimize postacute facility and resource utilization
1
2
3
4
5
VTED = venous thromboembolism disease.
31. BPCI Initiative: Clinical Management
Throughout the Pathway
The Importance of Care Coordination
• Enforces best practices/ standardization of pathways, workflows, and order sets
• Improves communication between providers and with the patient
• Ensures follow-up after care transitions
• Optimizes patient expectations and outcomes
• Identifies patients who would benefit from preoperative health status optimization
31
Surgeon Preop Visit
Preadmission
Testing
Preoperative Care
Preoperative Pathway
Skilled Nursing Facility
Inpatient Rehab
Home Health Agency
Outpatient Physical Therapy
Surgeon Follow-up Visits
Primary Care Visits
Postacute
Care
Shared Postacute
Pathways
Hospital
Acute Care
Inpatient Pathway
Goal
Develop a pathway with >80% use of all elements with exclusion
determined by pathway criteria, not physician preference
Hospital
32. BPCI Care Management/Coordination
32
Pre-hospital Inpatient Post-discharge
• Call/meet with patient before
surgery – complete preadmission
assessment
• Confirm contact information
• Review preoperative office visits/
PAT results
• Ensure Patient Engagement Form
is completed and brought to PAT;
reinforce Patient Engagement
Form
• Provide preadmission education
and discuss hospital processes
• Review expectations around
surgical limitations, preparation for
after hospital plan and discharge
needs/options.
• Provide patient with contact
information and encourage patient
to call back if questions arise
• Home visit – high-risk patients
- Monitor patient's progress
status
and readiness for discharge
- Monitor the Social Worker
and Case/Care Manager to
ensure that post-discharge
services are in place
- Ensure the patient is on
track for the expected
discharge date and work
with the in-hospital team if
there are barriers, as
needed
-Respond to escalation of
change in discharge
disposition from home to a
facility
-Maintain communication
with the surgeon, discharge
planning team and other
consults, as needed
• Timely and ongoing contact with
patients/coaches to monitor progress
and identify any issues
• Calls and electronic communication
to PAC providers
• Monitor SNF/IRF patient readiness for
CHHA services or outpatient services
and necessary follow-up appointments
• Monitor CHHA patient readiness for
self-care care and any necessary
follow-up appointments, including
outpatient PT
• Alert surgeon and specialty consult(s)
when changes have occurred during
the postacute period
• Follow guidance regarding patients who
refuse contact and when not able to
contact patients
• Plan for and establish closure at the
end of the 90-day period
33. Conclusions: What Does the Future Hold?
Changing the anesthesia and pain management standard of
care is needed to achieve desired outcomes
Increasing number of same-day discharge total joint arthroplasty
patients with continued multidisciplinary approach
Discharging many of our total hip arthroplasty (THA) and
unicondylar knee replacement patients same day
Expanding same-day discharge to total knee arthroplasty (TKA),
THA, and total shoulder replacements
Training on appropriate injection techniques
33
34. Relative Cost of 90-Day Episodes of
Bundled Care by Postacute Setting at
NYULMC-HJD
All postacute Medicare
costs incurred within the
90-day bundle are
categorized by the initial
postacute setting (ie,
includes readmissions
and other levels of care
following the initial
setting)
34HHA = home health agency; IP = inpatient; NYULMC-HJD = New York University Langone Medical Center Hospital for Joint Diseases;
SNF = skilled nursing facility.
35. Postacute Goal – Improved Outcomes and Patient
Experience: NYULMC Postacute Partners
•Developed in collaboration
with partners standard
postacute pathways
•Focus on:
•Bi-directional electronic
exchange of information
•Twice weekly updates on high-
risk patients
•Interdisciplinary weekly call
•PAC report card
•Quarterly PAC committee
meeting
35
NYULMC clinicians and staff selected facilities based on a set of
rigorous quality and care coordination criteria, taking into account
existing clinical relationships, patient geography, and physician
discharging preferences.
NYULMC = New York University Langone Medical Center; PAC = postacute care.
36. New York University Lutheran: Augustana and
Other SNF Average Length of Stay (ALOS)
36
Updated with Medicare Bundled Payment claims received February 2016.
SNF = skilled nursing facility.
Postacute ALOS per Month
37. Five Pillars of Alternative Payment Methodology Success
Conclusions
37
Optimize patient selection and comorbidities
Optimize care management/patient education/expectations
Use a multimodal pain management protocol, minimize narcotics
Venous thromboembolism disease risk standardization and optimized
blood management
Minimize postacute facility and resource utilization
1
2
3
4
5
Data, transparent data, real-time data,
believable data, accurate data…
39. Implementing Bundled Payment in Your Practice
Summary
• Care Management, Pain Management, Blood/VTED Management are critical to
bringing value to the TJA episode
• Optimizing the patient’s medical status and outcomes utilizing the integration of
internal medicine, primary care, anesthesiology, physical therapy, bariatrics,
nutritional services, endocrinology, cardiology, and psychiatry into the pre-
admission and pre-operative preparation process is critical, POSH
• Shared Decision making and patient buy-in
• NYULMC is developing a risk stratification coordinator position to manage poorly
optimized patients, currently this is surgeon driven
• In today’s bundled payment and quality driven environment, it is no longer
economically feasible to simply accept increased risk in poorly managed patients.
We have chosen to take an active role in managing modifiable risk factors and
will delay surgery until these risk factors are optimized
39
40. Nuances of BCPI
40
Conclusions
•Evidence based, cost effectiveness analysis
•Standardized protocol adoption
•Careful Patient Selection, Preoperative Patient Optimization
•Watch out for Prosthetic treatment of Hip Fx, conversion THA, TAA
•Transparent data, Physician alignment and Gain sharing, Surgeon
Champion
•Alternative payment models are an opportunity for AR orthopaedic
surgeons to control the episode of care and share in the value
generated by high quality, cost effective care
•Value based care is the best way to care for our patients