In this presentation, we will review the likely trends in healthcare going forward, including bundled payment programs. We will define the two major bundled payment programs involving joint replacement and discuss opportunities for acute pain services to add value.
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The Joint Replacement Bundle: Implications for Patients and Acute Pain Services
1. @EMARIANOMD
Joint Replacement Bundle:
Implications for Patients and
Acute Pain Services
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
12. @EMARIANOMD
What Is Bundled Payment?
“[A model of care] which link payments for
the multiple services beneficiaries receive
during an episode of care. Under the
initiative, organizations enter into payment
arrangements that include financial and
performance accountability for episodes of
care. These models may lead to higher
quality and more coordinated care at a
lower cost to Medicare.”
https://innovation.cms.gov/initiatives/bundled-payments/
13. @EMARIANOMD
What Is Bundled Payment?
http://www.kpmginfo.com/healthcare/PDF/bundled-payments-for-patients-providers.pdf
Bundled Payment Care Improvement (BPCI) Initiative
Began in 2013 (Voluntary)
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BPCI Initiative for Arthroplasty
Model 1: inpatient stay only (phased out)
Models 2 and 3: retrospective payment
against targeted price based on 3-year
institutional averages
– Model 2: inpatient hospital stay + acute
postoperative 90-day period
– Model 3: only acute 90-day postoperative
period
Model 4: prospective payment model
https://innovation.cms.gov/initiatives/bundled-payments/
Siddiqui, et al. J Arthoplasty 2017;32:2590
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Positives
Development of clinical
pathways
Increased patient
education
Decreased length of stay
Decreased admission to
rehab
Decreased cost of care
Decreased readmissions
Negatives
Shared risk by providers
Unanticipated
infrastructure costs (e.g.,
EMR, dashboards)
Unanticipated staffing
costs (e.g., clinical care
coordinators)
https://innovation.cms.gov/initiatives/bundled-payments/
Siddiqui, et al. J Arthoplasty 2017;32:2590
BPCI Initiative for Arthroplasty
17. @EMARIANOMD
Comprehensive Care
for Joint Replacement (CCJR)
https://innovation.cms.gov/initiatives/cjr
Started in 2016 (Not Voluntary)
Implemented in “67 geographic areas, defined by metropolitan statistical
areas (MSAs). MSAs are counties associated with a core urban area that
has a population of at least 50,000.”
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Comprehensive Care
From 67 mandatory
metro areas (initial)
33 become voluntary
34 stay mandatory
unless rural or low-
volume (<20 LEJR
during 3-yr period)
Final rule pending
for Joint Replacement (CCJR)
https://innovation.cms.gov/initiatives/cjr
Federal Register Vol. 82, No. 158, Aug. 17, 2017
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Perioperative Surgical Home (PSH)
“a patient-centered, physician
anesthesiologist-led, multidisciplinary team-
based practice model that coordinates
surgical patient care throughout the
continuum from the decision to pursue
surgery through convalescence.
Mariano, et al. A&A 2015;120:1163
Kain, et al. A&A 2014;118:1126
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“Unlike current questions, which ask about
the efficacy of pain treatment, the new set
will focus on the communication between
doctor and patient about pain.”
http://www.nytimes.com/2016/08/05/health/pain-treatment-
hospitals-emergency-rooms-surveys.html?_r=0
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Summary
We discussed:
– Introduction to Bundled Payment
– Comprehensive Care for Joint
Replacement
– Opportunities for the Acute Pain Service