As healthcare costs continue to grow, value-based initiatives like bundled payments are here to stay and are increasingly moving to the ASC setting.
The outpatient space is going to continue to explode as a lower cost setting, especially for patients who need a defined pathway of care, like a total knee or hip replacement. However, running a bundled payment program in an ASC setting can be especially complex to get off the ground since bundles originated in hospitals.
Three bundle experts — Ritesh Shah, MD, an orthopedic surgeon at Morton Grove-based Illinois Bone and Joint Institute; Lorraine Hutzler, associate program director of NYU's Center for Quality and Patient Safety; and James Slover, MD, an orthopedic surgeon at NYU Langone — provided their guidance on bundles in a joint session sponsored by Pacira at the Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs.
They outlined the following seven pillars of a successful bundled payment program:
1. Coordinate care throughout the entire episode. Providers need to ensure their patients follow the care pathways designed for them in the bundle. This starts with formal patient preparation before surgery to set expectations for the episode of care and create a plan of action. Dr. Shah's ASC hired a few people to help coordinate the process and get the ball rolling. "You realize there are a lot of other things you have to think about outside of surgical care," he said.
Dr. Slover noted how important it is to have everyone involved giving patients a unified message. "You can have care coordinators, but the surgeon has to reinforce this message," Dr. Slover said. Some of this preparation is simple, Dr. Slover noted. Details like deciding and contacting the person who will drive the patient home from the hospital are critical so the caretaker knows the appropriate time and place to pick up the patient. "If you are asking that question on the day of surgery you've got a problem," he said. After surgery he advised providers to make themselves available. "We try very hard to give patients a lot of ways to reach us after discharge," he said.
2. Identify risk factors and modify them before surgery. The more ASCs can formalize the process of identifying patient risk factors, such as smoking, diabetes and staph infections, and addressing them, the more successful they will be with their bundles. High-risk patients may not be the best candidates for ASC-based surgeries unless they can make changes to modify and reduce those risks. "If you have a patient that has a condition that can be modified, I think it's ethical to delay the surgery to do that," he said. This is not "lemon dropping and cherry picking," according to Dr. Slover, rather, it ensures patients have the lowest risk of complication before surgery.
3. Align all stakeholders. "You can't do this alone, no matter who you are," Dr. Slover said. It is a lot of work at the local level to get a bundle off the ground, and it may require arrangements like gainsharing to really engage and motivate people around the model. Dr. Shah's Illinois Bone and Joint Institute is horizontally integrated across 18 hospitals and seven healthcare systems as a surgeon group. It has participated in BPCI since 2014. Aligning all the stakeholders — including patients, surgeons and hospitals — has been a key to their success so far.
In the first year of the program, IBJI completed 115 joint replacements with just two complications. They have now treated roughly 350 patients through their bundle. The alignment within Dr. Shah's team helps make the process safe in the ASC-setting, he said. "I think it's actually more safe [than the hospital.] The difference is you know what you are going to get," Dr. Shah said. From the anesthesiologist to the nursing team to the physical therapy team, all aspects of care are carefully coordinated. "Everybody on this team has to be held accountable," he said. "It's not just the surgical technique. It's not just a multimodal pain pathway. It's not just patient education."
4. Use evidence-based clinical pathways. "Hospitals have to look at factors that result in poor outcomes and high costs," Ms. Hutzler said. "Many are controllable." Hospital-acquired conditions are the biggest "bundle busters," she said. The most expensive HAC is central line-associated blood stream infection, which costs an average of $45,814 per case, followed by ventilator-associated pneumonia. Having a system of care backed by evidence-based clinical guidelines will help reduce the incidence of HACs and address them when they do arise.
"You want to look at all of this in an evidence-based way and create an order set that keeps everyone on the same page," Dr. Slover said. For example, providers are often too quick to give patients blood transfusions without a full evaluation. Only patients that symptomatically need transfusions should be receiving them, Dr. Slover said, as they often have negative outcomes including greater length of stay, longer physical therapy and increased chances of surgical site infection, as well as higher costs.
5. Maximize quality. Metrics are important to success, from patient satisfaction to readmissions to infection rates. Providers must track metrics throughout the bundle to understand how to maximize the quality of care they are providing. For example, readmissions tend to spike in the first days after surgery, but can continue to occur throughout the episode. Readmissions that occur later in the episode of care may seem unrelated to the surgery, but 90 percent of the time they are found to be connected, according to Dr. Slover. Many of the most common reason for readmissions are GI issues, fractures and falls, all of which will add significant cost to the bundle — and indicate areas where quality and coordination can be improved.
One of the most challenging metrics to manage can be patient satisfaction, particularly related to pain, according to Ms. Hutzler. HCAHPS surveys linking patient satisfaction to pain control have become a "tremendous issue" with the opioid epidemic, she said. Studies show patients using prescription opioids are 32 percent more likely to report high satisfaction with their care, and patients have come to expect little to no pain after surgery. HCAHPS has updated its questions related to pain, and providers must update their strategies as well by managing patient expectations and talking with them about how to treat their pain.
6. Establish a robust data collection and dissemination infrastructure. This requires major commitment from organizations, but it is essential to success. Data needs to be accurate, transparent, actionable and physician-specific. IBJI uses bundled care pathway that works for the patient to promote quick and safe recovery, that uses only essential resources and has the best outcomes in their viewpoint. Underlying the entire pathway is data — transparent data, according to Dr. Shah. His group uses non-blinded, physician-specific data so surgeons can plan an entire episode and see how the case is progressing in real time.
"The ability to collect patient-reported outcomes is tied to how easy the technology is to use and your ability to make actionable changes in the practice," he said.
7. Control post-discharge care and cost. Send patients home when at all possible to keep costs down, according to Dr. Slover. Skilled nursing facilities tend to be significantly more expensive and may negatively impact outcomes as well, he said, though there may be some selection bias based on the difference between patients who are cleared to go home after surgery versus those sent to a SNF. When NYU started its bundle, it had 60 percent to 80 percent of patients going to facilities after surgery. That is now down to less than 25 percent, Dr. Slover said. To continue to drive that down in the future, he sees technology playing a major role, potentially using an app or email to keep in touch, gather information and provide educational resources.
Sending more patients home after surgery is also based on decisions throughout the episode of care. Patients need to get up and walk as soon as possible after surgery, which typically requires multimodal pain management techniques that may include bupivacaine liposome injectable suspension to reduce the use of opioids and other painkillers, according to Dr. Shah. Patients also need to be educated about the risks of going to a SNF. "In the area I work in, historically patients have had a huge rate of SNF after surgery. If you don't have the data to show them [infection rates are higher in SNFs], it's hard to convince them," he said. And for those patients who do have to go to SNF, finding the lowest cost partner is key. Dr. Shah's practice created narrow networks of preferred post-acute providers to help control post-surgery costs.
"We know that innovation leads to change," Dr. Shah said. "We know that change is the only way to lead to progress. The difficulty in healthcare is embracing change."
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