Results of Care Redesign for Joint Arthroplasty in the BPCI Program in an Independent Physician-Owned Orthopedic Group.

BACKGROUND: The Bundled Payment for Care Improvement initiative is a program designed by Center for Medicare and Medicaid Services in an attempt to increase the value of care delivered to Medicare recipients by rewarding providers who can deliver more cost-efficient, high-value care. This article reports the results of a coordinated care redesign program in an independent, medium-sized private-practice orthopedic group.
METHODS: A committee of stakeholders worked to redesign care protocols for patients receiving upper and lower joint replacement procedures. These protocols included preoperative, intraoperative, and postoperative care. Baseline metrics for post-acute care and readmissions were compared to the same metrics after initiating care redesign.
RESULTS: Incidence of discharge to inpatient facilities decreased as did length of stay at these facilities. Home health utilization and readmission rates were lowered. Average cost of the 90-day episodes decreased to a statistically significant degree.
CONCLUSIONS: These initial results indicate that coordinated care redesign in the private practice setting can yield higher value care with decreased utilization of high-cost care, particularly in the post-acute period.

Introduction

Rising health-care expenditures in the United States continue to be one of our largest domestic challenges. National health-care spending is projected to grow an average rate of 5.6% per year through 2025 [1]. This is expected to represent almost 20% of GDP by 2025. The federal government is responsible for the largest portion of this expenditure.

Orthopedic surgery represents a significant share of this expenditure. It is estimated that hospital costs of $16.5 billion in 2014 were related to treatment for osteoarthritis [2]. The Center for Medicare and Medicaid Services (CMS) is responding to this challenge by attempting to shift to value-driven reimbursement rather than volume-driven reimbursement. In 2011, CMS implemented the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty [3]. This initiative was designed to hold accountable and incentivize providers to provide more coordinated high-value care intended to improve quality and decrease cost for this expensive intervention. The BPCI program is a voluntary program and similar to the Comprehensive Care for Joint Replacement program which is a mandatory bundled payment program for joint replacement.

Results of the BPCI program have been quite promising as they have been reported by large academic and tertiary care centers [4]. Our hypothesis is that smaller independent practices can also decrease costs and maintain quality in this program. The purpose of this study is to report the results of care redesign through the BPCI program in the setting of an independent, medium-sized physician-owned orthopedic practice.

Material and methods

Coastal Orthopedics elected to participate in the BPCI program in cooperation with Signature Medical Group as an awardee-convener. The group initially analyzed the CMS data regarding baseline metrics to assess the opportunity. [PRACTICE NAME] decided to participate with a September 2014 go live date. The group put together a care redesign BPCI committee consisting of surgeons, administrative leaders, physical therapy providers, and operations and IT experts. A nurse case manager was selected to lead the team. A care redesign process was undertaken to create standardized, best practice–based care pathways to include preoperative assessment, intraoperative and in-hospital factors, and post-acute care. Patient modifiable risk factors were assessed, and surgery was not performed (with rare exception) in patients with a hemoglobin A1c greater than 7.5 and a BMI greater than 40. These patients were given resources to improve these risk factors. Intraoperative changes included standardization of preoperative antibiotic regimen and the use of tranexamic acid. Emphasis was placed on designing a variety of post-acute care pathways that would best meet the patient's needs while trying to avoid low-value care. Every patient had a care plan developed preoperatively which outlined their care pathway with a schedule of expected interventions to include all post-acute care needs. Results were based on claims data obtained from CMS as part of the BPCI program.

Percent change from baseline was calculated for each year (2015, 2016, 2017, and 2018) after protocol redesign for joint arthroplasty. A one-sample t-test was used to evaluate if there was a significant change from baseline (two-tailed) for the following variables: inpatient rehabilitation facility (IRF) incidence, IRF length of stay (LOS), skilled nursing facility (SNF) incidence, SNF LOS, home health (HH) incidence, HH visits, outpatient physical therapy (OPPT) incidence, OPPT visits, readmission rate, and average episode cost. All statistical analyses were conducted with R (R core team 2018). An alpha value of 0.05 was used for all analyses.

Results

Baseline data were based on historical claims data from mid-2009 to mid-2012 obtained by CMS. Baseline data, as well as data from the 4-year study period, are included in Figure 1. There were 1347 elective cases in the baseline period. In our group’s first complete year of the BCPI program (2015), there were a total of 544 eligible elective surgery episodes. Years 2, 3, and 4 of the program had 586 episodes, 603 episodes, and 449 episodes, respectively. Some patients were excluded based on program guidelines for BPCI.

Figure 1

Table containing all data used in this publication.

Incidence of discharge to an IRF incrementally decreased each year from a baseline level of 4.1% to 1.5%, 0.5%, 0.5%, and 0.7% in years 1, 2, 3, and 4, respectively. Incidence of discharge to a SNF was reduced from a baseline of 44.1%, to 29.2%, 22.5%, 16.3%, and 11.4% in years 1, 2, 3, and 4, respectively. Average SNF LOS decreased from a baseline level of 21 days to 9.9 days in year 4.

HH utilization decreased from a baseline of 83.5% to 55.5% by the end of year 4. Total HH visits per episode decreased from a baseline of 13.1 to 6.8 by the end of year 4.

OPPT utilization nearly doubled from a baseline of 43.9% to 86% after year 1 and remained above 90% for years 2, 3, and 4. OPPT visits per episode ranged from a low of 9.7 visits in year 1 to 13.8 visits in year 4. The incidence of the use of various types of post-acute resources is shown graphically in Figure 2.

Figure 2

Graph illustrating postsurgical treatment incidence.

The baseline all-cause readmission rate was 6.7%. Readmission rate during the study period varied from a low of 4.6% in year 2 to a high of 6.7% in year 4, averaging 5.7%.

Total costs for the 90-day episodes were decreased in each year of the study relative to baseline (Fig. 3). The baseline historical cost for an elective joint replacement episode was $23,684.00. After care redesign was implemented, elective joint replacement episode cost decreased to $20,242.00 in year 1, $18,590.00 in year 2, $19,050.00 in year 3, and $18,628.00 in year 4.

Figure 3

Graph illustrating cost of care.

Quality metrics which were measured through claims data from CMS were followed during the study period and compared to baseline. These are shown in Figure 4.

Figure 4

Table containing CMS quality metrics data.

Discussion

Preliminary results of this program have been promising and described by larger, academic medical centers. Dundon et al described decreased LOS, utilization of inpatient post-acute care facilities, readmissions, and cost at a large, tertiary, urban academic center [4]. Iorio et al also showed positive results in a large, tertiary, academic medical center [5].

Our results indicate that independent physician groups have the capability to lower costs while maintaining quality. We were able to decrease utilization of inpatient rehabilitation and skilled nursing facilities as well as decrease LOS when these facilities were used. We were able to move patients more quickly into the ambulatory setting where costs are lower. Some of the cost reduction came through decreased readmissions. Clearly reduction in cost cannot come at the expense of quality. Therefore, measurement of quality data is important in this type of program. In this study, we saw favorable change in most quality metrics.

Quality metrics that were followed included index admission pulmonary embolism, deep vein thrombosis, urinary tract infection, pneumonia, sepsis/shock, and joint infections. Other quality metrics were acute myocardial infarction within 7 days, joint infections within 30 days, overall surgical site infection, complications of wound dehiscence, readmission within 30 days, and revision. Acute LOS was also measured. During the study period, we saw statistically significant decreases in the rate of acute myocardial infarction within 7 days, surgical site infection, and acute LOS. We saw no statistically significant change in any of the other quality metrics.

Health-care costs in the United States continue to rise at unsustainable rates. At the current rate of growth, the cost of health care in our country will exceed 20% of GDP [6]. Fortunately, there is a growing sense of urgency to control costs while maintaining or improving quality of care in our system. This is the essence of “value” [7].

Care for musculoskeletal problems is expected to grow dramatically as our population ages [8]. The demand for elective joint arthroplasty alone is expected to grow from approximately 1 million surgeries in 2010 to approximately 1.5 to 2 million procedures by 2030 [9]. This demand will require new and innovative ways to drive value in the delivery of musculoskeletal care.

Orthopedic surgical care in most cases is episodic in nature, with relatively clear starting and ending points, and is particularly suited to alternative reimbursement methodologies. Alternative reimbursement methodologies have the capability of incentivizing stakeholders to collaborate in ways that can eliminate waste (low-value care), lower cost, and improve care [5].

The BPCI program was implemented by CMS to accomplish these goals [3]. The BPCI program is a physician-controlled program that has a variety of formats designed to promote care coordination and value-based care [5,10]. This article describes the experience of a medium-sized independent, physician-owned practice with this program.

Our group used Signature Medical Group as an awardee-convener and selected model 2 of the program. [3] We chose Diagnostic Related Groups 470, 469, and 482 that represent major upper and lower extremity joint replacement. We elected to go live with the program in the fourth quarter of 2014. Before initiating the program, we devoted significant resources to redesigning our processes for providing joint arthroplasty. A committee was formed to oversee this process, which included surgeons, senior business and operations leaders, physical therapists, and IT specialists. We hired a nurse case manager to lead the program. We then set about an evidence-driven, care redesign process to standardize care before surgery, during the hospitalization, and during the post-acute care phase. Our focus was on limiting care variation and creating individualized care plans for each patient based on their medical and social factors. Preoperative optimization of patient modifiable risk factors was performed. Resources including utilization of a nutritionist and improved communication with primary care providers were developed to assist patients in improving these risk factors. Perioperative processes were examined and standardized in an attempt to reduce variation. A program was put in place to attempt to reduce implant and supply cost. Special care was taken to reduce cost during the post-acute period by decreasing unnecessary utilization of high-cost services such as inpatient rehabilitation and skilled nursing facilities. A preferred care provider network of skilled nursing facilities and HH providers who were interested in participating with our protocols was developed. Patient choice was maintained while informing patients about this preferred network. Additional services were provided through specific BPCI waivers to meet patient’s needs in lower cost settings.

It should be noted that the group incurred significant expense for the initiation and ongoing administration of this program. Before the initiation of the program, the group spent approximately $24,000 in direct costs for a case manager and software expense. More difficult to quantify is the cost of time spent by the administrative team and physician champions designing and implementing the program. We would estimate that between 100 and 150 man-hours of work time were spent by this group of people during the setup of this program. The costs directly attributable to the program gradually escalated from $113,000 in 2015 to and annualized cost of $228,000 in 2018, primarily from increased staffing costs and increased use of services covered under the waiver. Administrative time continued to be spent by the management team and physicians throughout the program for monitoring, accounting, and compliance purposes. Also of note is that the cost for third-party convener services was significant. Our arrangement was that 35% of our upside savings was paid to the convener for their services. The design of these programs going forward will need to take these costs into account if they are to remain viable for participants.

We believe all stakeholders have benefitted from this process. Our hospitals have seen lower readmissions rates and more coordinated care for their patients. Our patients have experienced more standardized, evidence-driven care. Patients have appreciated a planned, written care pathway. Our physicians have experienced higher reimbursement while CMS has seen a lower overall cost for these episodes. Our group found that the most effective factor in achieving cost savings was surgeon engagement in the process. Of the aforementioned activities, our group believes that the single most effective factor for cost-savings was limiting low-value post-acute care costs at inpatient rehabilitation and skilled nursing facilities. This was primarily accomplished by face-to-face discussion between the surgeon and the patient regarding their social situation and family support. This was followed up on by the case manager, which resulted in most utilization of low-cost post-acute services, rather than high-cost services.

This study includes elective arthroplasty cases only. It is of note is that patients who had surgery for fractures rather than elective joint arthroplasty had very different resource utilization patterns. Fracture patients did not afford us the opportunity for significant preoperative optimization and post-acute care planning. This article excludes these patients and focuses on elective arthroplasty patients.

The BPCI program is similar to the mandatory Comprehensive Care for Joint Replacement program the CMS has implemented but is currently scaling back. It is our belief that physician-led programs such as BPCI have a better chance to succeed because the physicians themselves are best suited to design the care pathways for their individual patients based on their unique medical and social situations. We have concerns about the future of programs such as BPCI and the new version BPCI-Advanced. If the target price continues to be lowered based on prior performance, we will eventually reach a point where the risk-benefit ratio will not favor participation in the program. This “race to the bottom” characteristic of program design has already forced many orthopedic groups to stop participating in certain episodes and, in some cases, to drop participation completely. It is our belief that the program should be designed to be sustainable by continuing to reward groups that put forth the effort, expense, and risk of participation.

Limitations of this study include that the results are fairly preliminary with only 4 years of experience. Longer term results will determine if these gains are sustainable. Another limitation of our study is the relatively limited data we have on outcomes. While readmissions cost data and our chosen quality metrics are important, longer term outcomes such as function and implant longevity will need to be measured. Patient-reported outcomes including satisfaction would be useful data as well.

A concern with these types of programs is the potential to limit care for the higher risk patients with more comorbidities. Safeguards will have to be put in place to avoid “cherry-picking” the healthiest patients that are likely to cost the least. That being said, we believe strongly in responsibly mandating optimization of patient-modifiable risk factors such as BMI, control of diabetes, smoking, and so on.

Conclusions

This study shows institution of care redesign in a retrospective bundled payment program within an independent, medium-sized orthopedic practice can result in decreased episode cost without sacrificing quality. Scrutiny of outcomes and quality metrics continues, and further longitudinal assessment is ongoing to determine the value of bundled payments over time for lower extremity arthroplasty episodes of care.

Conflict of interests

Arthur L. Valadie: speakers bureau/paid presentation, Stryker; paid consultant, Stryker; board member, Ortho Forum. Alan L. Valadie: royalties, Arthrex; speakers bureau/paid presentation, Arthrex; paid consultant, Arthrex. D.V. Cashen: principal investigator of Coastal Orthopedics and Sports Medicine, paid consultant, Maxx Orthopedics; principal investigator for Maxx Orthopedics.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2020.12.027.