When former HHS Secretary Tom Price, MD, issued a proposed rule in August to cancel and scale back several Medicare bundled payment initiatives, it may have sounded like a death knell for bundles.
However, it didn't deter Joseph Bosco, MD, professor and vice chair of The NYU Langone Department of Orthopedic Surgery. "Bundles are very much alive and well," Dr. Bosco said during an Oct. 27 presentation sponsored by Pacira Pharmaceuticals at the Becker's ASC Review 24th Annual Meeting: The Business and Operations of ASCs, held in Chicago.
Dr. Bosco believes the implementation of the Medicare Access and CHIP Reauthorization Act's Quality Payment Program solidified the future of bundled payments. Bundles are the most popular model under the Advanced Alternative Payment Model track and are effective in engaging healthcare professionals across the care continuum, from surgeons to lab technicians. "No doubt, Medicare bundled payments are here to stay," Dr. Bosco said, and he expects commercial payers to follow suit. "That's where we all think the future is headed."
By investing in bundled payments now, providers can best position their organizations for financial and clinical success in the future, according to Dr. Bosco. During the presentation, he outlined the following seven pillars of success for bundled care.
1. Coordinate care throughout the episode. Every patient involved in a bundle should be assigned a clinical care coordinator, Mr. Bosco advised. "Every step of the way, there's a constant message," he said.
2. Identify and modify patient risk factors preoperatively. "You want to know about risk and modify it beforehand so you can prevent risk afterwards. That's just good medicine," Dr. Bosco said, even if it means surgery has to be delayed. Some modifiable risk factors include smoking cessation or having a patient's nose decolonized to reduce risk of infection. High-risk patients can also be coded at a higher complexity, Dr. Bosco noted.
3. Use evidence-based clinical pathways. This will decrease variation in treatment and cost. Physicians may have different ideas about pain management and blood transfusions, for example. Establishing a clinical pathway based on evidence will standardize care and reduce costs across the ASC's patient population.
4. Identify and align with stakeholders. Due to the all-encompassing nature of bundled payments, there are a lot of stakeholders, such as anesthesia, physicians, pharmacists, physical therapists and social workers, Dr. Bosco said. Ensuring these parties are on the same page will go a long way in ensuring bundles are successful.
5. Maximize and demonstrate quality. The long list of available quality metrics can be daunting. "There's a whole alphabet soup of quality metrics," Dr. Bosco said. "It seems like every day they come up with new ways we have to track quality." However, Dr. Bosco advised providers to focus on the three quality metrics the government is primarily concerned with: hospital-level risk-standardized complication rates, HCAHPS scores and patient-reported outcomes.
6. Measure and report outcome clearly and concisely. Providers need to provide stakeholders with timely, accurate, transparent and actionable data, which means it needs to be available in real time, according to Dr. Bosco. If you wait to see how you performed at the end of the bundle — it's too late to change behaviors that may be driving up cost or reducing quality. "The businesses that have the best, most robust, most real-time, actionable data will perform the best," he said.
7. Control post-discharge care and costs. For commercial bundles, patients will generally be younger and healthier — meaning fewer commercial bundle patients will need to go to skilled nursing facilities and managing post-discharge costs will be less important than managing acute care costs. However, Dr. Bosco said, "For Medicare total joints, [post-discharge care is] where all the savings will occur."
Managing post-discharge care costs was integral to the success of the bundled payment program at Morton Grove-based Illinois Bone and Joint Institute, according to the practice's medical director of research, Ritesh Shah, MD, who took the floor after Dr. Bosco. IBJI is participating in the Bundled Payments for Care Improvement Model 3, which is a practice-based model that includes post-acute rehab care.
Undertaking this initiative at IBJI was no small undertaking. IBJI is the state's largest musculoskeletal practice and has 90 orthopedic surgeons who practice across 16 hospitals and six health systems. The practice focused on many of the pillars of success outlined by Dr. Bosco — standardizing clinical care pathways, working on the continuum of care, developing IT to manage and report data and especially focusing on post-acute care costs, which account for roughly half the cost of a total joint replacement episode, according to Dr. Shah.
IBJI worked to develop a partner network of high-performing SNFs and home health providers based on how well they performed in rehab care pathways. This coupled with surgeon engagement and education allowed IBJI to control its post-acute care costs.
"What we really found over the last three and half years is that needle does move. Surgeon behavior moves as surgeons are engaged in this and realize the quality is so much better," he said.
During its time in the bundled payment program, IBJI has been able to reduce readmissions from 11 to 6 percent, raise patient-provider communication rates from 10 to 80 percent, drive down post-acute care costs and improve patient engagement, according to Dr. Shah.
"One of the biggest opportunities here is if [you] can work in alternative modeling with bundled payments, you can change the trajectory of your practice," Dr. Shah said.
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