American Society of Regional Anesthesia and Pain Medicine May 2017 - 6
Initial Experience With Bundled Pay for Total Joint
Arthroplasty Procedures
T
he current healthcare landscape
is evolving to yield paradigms that
improve patient care and curtail
cost.1 Patient centric and collaborative
models that accentuate "value" as
opposed to "volume" are gaining
impetus.2-4 This is exemplified by the
Bundled Payments for Care Improvement
(BPCI) initiative of 2013 that aims to
study if holistic episode based payments
can diminish Medicare payments for
total joint arthroplasty (TJA) procedures
while perpetuating quality.5,6 The
purpose of this review is to outline initial
experiences with bundled payments for
TJA procedures and potential implications
on anesthesiology practice.
Navid Alem, MD
Leslie Garson, MD, MIHM
Department of Anesthesiology & Perioperative Care
There is consensus that existing
healthcare paradigms in the United
States are plagued by unsustainable cost inflation that does
not parallel enhanced patient outcomes.7 The current system
has been characterized as a broken model with widespread
waste, redundancy, and care fragmentation.7,8 Rather than
accepting the status quo, the Affordable Care Act (ACA) has a
multitude of initiatives and incentives that strive to strengthen
partnership amongst practitioners.8-10 A prominent element of
the ACA is savings and enhanced care achieved via accountable
care organizations (ACO); defined by Epstein et al10 as models
"in which various constellations of providers agree to assume
collective responsibility for the care delivered to a defined Medicare
population." The Medicare
Access and CHIP Reauthorization
Act of 2015 further manifests
the Centers for Medicare and
Medicaid Services (CMS) goal
of transitioning to merit based
incentive payment systems or
advanced alternate payment
models (such as Accountable
Care Organizations). CMS
also instituted the Hospital
Readmissions Reduction
Program in 2013, which includes
explicit provisions for payment
reduction after elective TJA procedures for hospitals with 30 day
readmission rates above national benchmarks.
School of Medicine, University of California, Irvine
Section Editor: Melanie Donnelly, MD
discussing whether to participate in bundled payment programs
but instead focusing on how to do the work necessary to succeed
under them." In contrast to a fee for service model, an integral
feature of ACOs is a progression toward bundled payments that
encompass comprehensive episodes of care.6 In an ACO, it is
incumbent upon hospitals, physicians, and post-acute care
providers to collaborate and restrain both the quantity and cost of
unnecessary and non-evidence based services.12,13 Demonstrating
patient centric value contribution is paramount in so called
"incentive compatible" paradigms that aim to marginalize individual
predilections.14 Value is essentially a global assessment of quality
in relation to cost.3,4,15 In
the context of perioperative
care, appraisal of quality is
linked to longitudinal patient
dispositions, such as the
haste with which patients
return to baseline function.3
"As forthcoming payment models are
dynamically redefined, it is sensible
for anesthesiologists to explore
expanding roles that augment both the
scope and quality of patient interaction
during the surgical course."
Health care delivery redesign is being accelerated by a long needed
transition in payment systems towards value based paradigms.
Porter et al11 elucidate, "The clear message is that hospitals, health
care centers, and clinicians should no longer be spending time
62
Zeev Kain, MD, MBA
Center for Stress & Health and
Department of Anesthesiology &
Perioperative Care
While there is timely evidence
that has demonstrated both
cost savings16 and improved
patient experiences17 in ACO
paradigms, outcomes in the
setting of surgical procedures
are only recently materializing by analyzing the experience with
BPCI for TJA. In 2016, CMS made bundled payments for total hip and
knee replacement mandatory in 67 regions under its Comprehensive
Care for Joint Replacement model.18 Within this context, Lee et al18
reported clinical outcomes were maintained along with an 11%
cost decline for TJA procedures. One key step toward enhanced
efficiency was modifying physical therapists' schedules so that
American Society of Regional Anesthesia and Pain Medicine
2017
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