The Impact of Technology and Alignment on Improving Value for the Total Joint Replacement Episode of Care
The Impact of Technology and Alignment on Improving Value Richard Iorio, MD Chief of Adult Reconstruction and TJA Service Vice Chairman of Clinical Effectiveness Brigham and Women’s Hospital Member of the Faculty Harvard Medical School Boston, MA James Slover, MS, MD Site Director New York Langone Orthopaedic Hospital Associate Professor of Orthopaedic Surgery New York, NY Ritesh Shah, MD Chairman of Centers of Excellence Illinois Bone and Joint Institute Morton Grove, IL
The Impact of Technology and Alignment on Improving Value TJA as a Model for Care Delivery The value based care landscape is rapidly changing. Implementing a bundle requires an investment in time, alignment and resources of all providers who care for bundled patients. This includes physicians, nurses, social workers and hospital administrators. The discipline necessary to be successful at bundled payments enhances the financial viability of hospitals and clinicians by benefitting the entire TJA product line, and most importantly, these strategies result in improved outcomes and better care for our patients, which is the ultimate goal of all providers As we move toward 90 day DRG’s for all payers, this discipline is imperative to be successful going forward
The Impact of Technology and Alignment on Improving Value ACA Without the Fake News In 2010, the Affordable Care Act was signed into law There were 45 million people uninsured which was roughly 16 percent of the population After 2017 with a full year of Trump and Republican efforts to eliminate the ACA, there are 26 million uninsured or 9.1% of the population There was no change in coverage from 2016 to 2017 Trump says that Obamacare is imploding and the Democrats say that Trump has sabotaged coverage programs What this CDC survey shows is that Americans will cling strongly to their health insurance 2 groups affected the most, the healthy working middle class and the poor in states which did not take on Medicaid expansion
The Impact of Technology and Alignment on Improving Value
The Impact of Technology and Alignment on Improving Value • MIPS is default payment system • CMS report cards for quality performance coming • Institutional and individual penalties • Hospital Surgeon Alignment is key for both stakeholders • Exemptions for: ➢ Participants in alternative payment models (CJR and BPCI do not count as advanced APM’s yet) ➢ Low volume threshold
The Impact of Technology and Alignment on Improving Value • CMS continues to support the concept of bundled payment programs due to their success in decreasing cost and improving quality • Although CMS has cut back the CJR MSA’s, CMS did not eliminate the program • CMS realizes it made a mistake with CJR and did not allow physicians to take on risk as episode initiators, and required some hospitals to take on risk they couldn’t afford • This led to less physician buy-in and a lack of urgency on the part of hospitals since there is no down side risk in the first year • In 2018, CMS has opened BPCI up again for conveners, episode initiators and physicians, in addition to hospitals (BPCI A). • This will represent an opportunity for physician groups and physician champions to seize control of the episodes and the financial gain that can be realized from optimal management of the TJA episode • Advanced APMs where physicians are required to take on risk will serve as a substitute for MIPS and will be a more reproducible measure of TJA quality than the generalized variables offered through MIPS
The Impact of Technology and Alignment on Improving Value Early Flaws in Bundled Payment Implementation 1. Care management, hire FTE’s and hope for the best ❖ Post operative care management attention will not solve most selection or optimization issues with patient 2. Hospital administered bundles without surgeon responsibility ❖ Physician led bundles or co-management arrangements have been clinically and financially much more successful than hospital only 3. Transparent Data ❖ Demonstrate through easily accessible, accurate, easily comparable data relative performance metrics to modify behavior, Hospitals reluctant to share or incapable of producing the data
The Impact of Technology and Alignment on Improving Value Conclusions after Year 1 of BPCI 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 then 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, HIV 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
The Impact of Technology and Alignment on Improving Value Five Clinical Pillars of Bundled Payment Success
The Impact of Technology and Alignment on Improving Value Current technology applications available for Patient Selection and OR Cost Efficiency • Perioperative Orthopaedic Surgical Home (POSH) and The Readmission Risk Assessment Tool (RRAT), Optimization • Implant Selection Guidelines • OR and Hospital Supply Control: Eliminate or ration Cell Saver, Aquamantys, antibiotic bone cement, and aggressive anticoagulation • Identify opioid dependent patients, catastrophizers • Identify Same Day Discharge candidates IPO rule • All of these protocols can be regulated through technology platforms and the EMR
The Impact of Technology and Alignment on Improving Value Interventions for Modifiable Risk Factors • MRSA Screening and Decolonization, weight based antibiotic dosing, and use of Vancomycin and Gentamycin in high risk patients, Hepatitis C and HIV 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) (SWIFT Trial) • 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 (Lipoprotein A, Factor VIII) • Risk adjusted VTED prophylaxis, use ASA and SPCD’s with standard risk patients, avoid aggressive anticoagulation
The Impact of Technology and Alignment on Improving Value 90-Day Readmission Rate of Medicare TJA Patients at NYULMC 16% 15% 14% 14% 12% 12% 10% 10% 9% 8% 8% 8% 6% Implementation of POSH 4% 2% 0% Q3 2009-Q2 Q3 2010 - Q2 Q3 2011 - Q1 CY 2013 CY 2014 CY 2015 CY 2016 2010 2011 2012 We lowered the readmission rate for CY2017 to 7.0% 13
The Impact of Technology and Alignment on Improving Value Medically-Optimized versus non-Optimized Cohorts since implementation of POSH: A Comparison of Quality Outcomes Discharge Odds ratio of 90-day 30-day Odds ratio of 30- disposition 90-day LOS, days readmissio readmission day readmission 1) Home Cohort (n=410) readmission (SD) n rates rates (CI 95%) 2) Inpatient (CI 95%) facility Medically- optimized 89.2% (Experimental) 4.6% 1.5% 2.4 (0.9) 10.8% (n=365) 0.422 0.627 (0.054 - 3.279) (0.079-4.994) Non-optimized (Control) 80.4% 5.7% 4.1% 3.1 (1.5) (n=65) 19.0% p-value 0.704 0.352 0.321 0.659 0.001 0.106
The Impact of Technology and Alignment on Improving Value POSH Index Admission Post Discharge Cost Total 90-day Cost Cost Non-Optimized $16,367.89 $13,704.96 $30,072.85 Optimized $16,619.83 $12,582.06 $29,201.89 Savings -$251.94 $1,122.90 $870.96******* - We lowered the length of stay in optimized patients…. p<0.001 - We lowered the readmission rates in optimized patients…. 5.7 to 4.6 -And we also saved money in those episodes which were optimized
The Impact of Technology and Alignment on Improving Value Five Clinical Pillars of Bundled Payment Success 1 Optimize patient selection and comorbidities 2 * Optimize care coordination/patient education/expectations Use a multimodal pain management protocol, minimize 3 narcotics 4 VTED risk standardization and optimized blood management 5 Minimize postacute facility and resource utilization
The Impact of Technology and Alignment on Improving Value 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 to the patient • Ensures follow-up after care transitions • Optimizes Patient Education, Expectations and Outcomes Goal Develop a pathway with >80% use of all elements with exclusion determined by pathway criteria, not doctor preference
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