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The Joint Replacement Bundle: Implications for Patients and Acute Pain Services

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The Joint Replacement Bundle: Implications for Patients and Acute Pain Services

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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.

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. 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
  2. 2. @EMARIANOMD Disclosures  No current financial disclosures (past 12 months)
  3. 3. @EMARIANOMD Healthcare Is Changing
  4. 4. @EMARIANOMD Let’s Review the Facts
  5. 5. @EMARIANOMD FACT: U.S. is Last Access Equity Outcomes
  6. 6. @EMARIANOMD FACT: “The Triple Aim” Berwick et al., Health Aff (Millwood) 2008;27:759 Vetter et al., Anesth Analg 2014;118(5):1131
  7. 7. @EMARIANOMD Kurtz S, et al. JBJS 2007 Apr;89(4):780 FACT: Arthroplasties Are Increasing
  8. 8. @EMARIANOMD Kurtz S, et al. JBJS 2007 Apr;89(4):780 FACT: Arthroplasties Are Increasing Now Over 1,000,000 THA and TKA Cases Annually
  9. 9. @EMARIANOMD FACT: MACRA Passed in 2015
  10. 10. @EMARIANOMD Overview  Introduction to Bundled Payment  Comprehensive Care for Joint Replacement  Opportunities for the Acute Pain Service
  11. 11. @EMARIANOMD Overview  Introduction to Bundled Payment  Comprehensive Care for Joint Replacement  Opportunities for the Acute Pain Service
  12. 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. 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)
  14. 14. @EMARIANOMD 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
  15. 15. @EMARIANOMD 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
  16. 16. @EMARIANOMD Overview  Introduction to Bundled Payment  Comprehensive Care for Joint Replacement  Opportunities for the Acute Pain Service
  17. 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.”
  18. 18. @EMARIANOMD Comprehensive Care for Joint Replacement (CCJR) https://innovation.cms.gov/initiatives/cjr https://qpp.cms.gov/apms/overview
  19. 19. @EMARIANOMD Comprehensive Care for Joint Replacement (CCJR) https://innovation.cms.gov/initiatives/cjr https://qpp.cms.gov/apms/overview
  20. 20. @EMARIANOMD 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
  21. 21. @EMARIANOMD Overview  Introduction to Bundled Payment  Comprehensive Care for Joint Replacement  Opportunities for the Acute Pain Service
  22. 22. @EMARIANOMD 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
  23. 23. @EMARIANOMD Elements of PSH PSH: Comprehensive Literature Review, www.asahq.org/psh
  24. 24. @EMARIANOMD Mariano, Walters, Kim, Kain. A&A 2015;120:1163 Walters, Mariano, Clark. Pain Med 2015;16:1666.
  25. 25. @EMARIANOMD Pain and Readmissions Hernandez-Boussard, et al. Ann Surg 2017;266:516 Postoperative pain trajectories identify populations at risk for 30-day readmissions and ED visits
  26. 26. @EMARIANOMD  “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
  27. 27. @EMARIANOMD Avoid “Never” Events Federal Register May 3, 2007
  28. 28. @EMARIANOMD Anesth Clinics 2014;32:853
  29. 29. @EMARIANOMD Summary  We discussed: – Introduction to Bundled Payment – Comprehensive Care for Joint Replacement – Opportunities for the Acute Pain Service

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