Subscribe to RSS
DOI: 10.1055/s-0036-1593613
Contracting Strategies for Arthroplasty—Bundles to Population Health
Publication History
24 July 2016
06 September 2016
Publication Date:
04 November 2016 (online)
Abstract
Orthopedics, and especially total joint replacement (TJR), is growing in payer prominence due to large projected increases in volume. The unsustainability of the fee-for-service payment system has lead Centers for Medicare and Medicaid Services to employ new value and risk-based contracting strategies on a population health basis and on an episode of care basis, with programs such as the Bundled Payment for Care Improvement program and the Comprehensive Care for Joint Replacement program. These trends are forcing hospitals and physicians to align to improve quality and reduce costs through new structures such as Accountable Care Organizations, comanagement programs, and gainsharing. Bundled payment programs are typically used to align specialists such as orthopedic surgeons and TJR has been on the forefront of bundled payment contracting strategies. Bundled payment programs with commercial insurers can create additional opportunities, as do commercial bundled payment contracts for TJR performed on an outpatient basis. As these programs are now becoming mandatory, surgeons must understand the structural aspects of these arrangements and the levers available to optimize the likelihood of success.
-
References
- 1 DRGs 121, 122 from 2000 to 2007 and MS-DRGs 280, 281 from 2008 to 2010. Available at: www.hcupnet.gov and www.iwcc.il.gov/crosswalk.xls . Accessed September 12, 2016
- 2 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (4) 780-785
- 3 Young BW. Joint replacement patients are not sick. Orthopedics This Week Inc. Published online: February 16, 2016. Available at: https://ryortho.com/breaking/joint-replacement-patients-are-not-sick/ . Accessed October 25, 2016.
- 4 Slover JD. You want a successful bundle: what about post-discharge care?. J Arthroplasty 2016; 31 (5) 936-937
- 5 London DA, Vilensky S, O'Rourke C, Schill M, Woicehovich L, Froimson MI. Discharge disposition after joint replacement and the potential for cost savings: effect of hospital policies and surgeons. J Arthroplasty 2016; 31 (4) 743-748
- 6 National Health Expenditures 2014 Highlights Available at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf . Accessed October 25, 2016
- 7 Evans M. Major providers, insurers plan aggressive push to new payment models. Modern Healthcare; January 28, 2015. Available at: http://www.modernhealthcare.com/article/20150128/NEWS/301289934/major-providers-insurers-plan-aggressive-push-to-new-payment-models . Accessed June 6, 2016
- 8 Urdapilleta O, Weinberg D, Pedersen S, Kim G, Cannon-Jones S, Woodward J ; Centers for Medicare & Medicaid Services. Evaluation of the Medicare Acute Care Episode (ACE) Demonstration. IMPAQ International, LLC and The Hilltop Institute; 2013. Available at: https://downloads.cms.gov/files/cmmi/ace-evaluationreport-final-5-2-14.pdf . Accessed May 1, 2016
- 9 BPCI Initiative Episode Analytic File (XLS) - (Updated from 04/04/2014). 2014. Stryker Performance Solutions analysis
- 10 Dummit L, Marrufo G, Marshall J , et al; Centers for Medicare & Medicaid Services. CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2–4: Year 1 Evaluation & Monitoring Annual Report. The Lewin Group; 2015. Available at: https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf . Accessed February 2015
- 11 Conway P. Extending participation in the Bundled Payments for Care Improvement initiative. The CMS Blog; 2016. Available at: https://blog.cms.gov/2016/04/18/extending-participation-in-the-bundled-payments-for-care-improvement-initiative/ . Accessed May 1, 2016
- 12 Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program. Fed Regist 2015; 80 (226) 73273-73554
- 13 42 CFR Part 510, III (A)(4)(b)(1)
- 14 Stryker Performance Solutions analysis of 100% Medicare claims files for MS-DRG 470 from January 1 - September 30, 2014
- 15 Iorio R. Strategies and tactics for successful implementation of bundled payments: Bundled Payment for Care Improvement at a large, urban, academic medical center. J Arthroplasty 2015; 30 (3) 349-350
- 16 Butcher L. Successful Physician-Hospital Alignment. Healthcare Financial Management Association; June 7, 2013. Available at: http://www.hfma.org/Leadership/Archives/2013/Summer_2013/Successful_Physician-Hospital__Alignment/ . September 12, 2016
- 17 Murphy SB, Bolz NJ, Terry DP, Talmo CT, Fehm MN. The physician as the provider at risk: rolling the dice. J Arthroplasty 2016; 31 (5) 938-944
- 18 Froemke CC, Wang L, DeHart ML, Williamson RK, Ko LM, Duwelius PJ. Standardizing care and improving quality under a bundled payment initiative for total joint arthroplasty. J Arthroplasty 2015; 30 (10) 1676-1682
- 19 Loftus T, Agee C, Jaffe R, Tao J, Jacofsky DJ. A simplified pathway for total knee arthroplasty improves outcomes. J Knee Surg 2014; 27 (3) 221-228
- 20 Healthdialog White Paper. A Clinical Approach to Population Stratification Analytics: Dispelling the Myths of Traditional Risk Segmentation Models used in Population Health Management Programs; June 2015. Available at: http://healthdialog.com/sites/default/files/whitepapers/A-Clinical-Approach-to-Population-Stratification-Analytics.pdf . Accessed September 12, 2016
- 21 American Academy of Family Physicians website. Available at: http://www.aafp.org/practice-management/transformation/pcmh.html . Accessed September 12, 2016
- 22 Meller MM, Toossi N, Johanson NA, Gonzalez MH, Son MS, Lau EC. Risk and cost of 90-day complications in morbidly and superobese patients after total knee arthroplasty. J Arthroplasty 2016; pii: S0883-5403(16):213–218
- 23 Herman B. The Advantages and Disadvantages of CMS' Bundled Payment Initiative: 8 Responses. Becker's Hospital Review. October 7, 2011. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/the-advantages-and-disadvantages-of-cms-bundled-payment-initiative-8-responses.html . Accessed September 12, 2016
- 24 Anderson J. Large employers are seeing surprising uptake of bundled pay: tourism benefits. Value Based Care News 2016; 7 (3) . Available at: https://aishealth.com/archive/nvbc0316-01 . Accessed December 19, 2016