Succeeding at bundles: The physician perspective
For hospitals in 67 markets affected by the Comprehensive Care for Joint Replacement (CJR) program, the first mandatory bundled payment model of CMS, 2016 was a year of uncertainty—particularly about the potential financial impact and the ways affiliated physicians might need to change their practice patterns.
It was also a year of exploration on how to best manage the post-acute portion of care episodes and prevent patients from being unwitting accomplices in the overuse of skilled nursing facilities (SNFs).
Some hospitals are taking a purely tactical approach to CJR, such as investing in more case management resources to facilitate the discharge of patients directly home. Others have responded more broadly by creating a multidisciplinary team—including multiple physician champions as well as representatives of case management, rehab and operations—to tackle care redesign. Two decades of experience with bundles suggests the latter is both the harder and more foolproof path to coping with the alternative payment model.
Where CJR teams exist, the possibility of extending rather than shortening hospital lengths of stay has emerged as a key discussion point, both to prepare patients for discharge home and better manage comorbidities so they're less likely to be readmitted. Conversely, interest in "enhanced surgical recovery" (aka "rapid recovery protocols") has also intensified. Common themes of these evidence-based protocols, whether homegrown or purchased commercially, are to expedite discharge by focusing care teams on preventing excess fluid retention that leads to complications, minimizing narcotic use that can slow down recovery, and getting patients up and walking two hours after surgery.
Hospitals are in pilot mode with the many new-to-market digital technologies designed to help them cope with the demands of value-based care. These include smartphone apps to keep patients connected to their care, and remind them to take their medication and keep follow-up appointments, as well as software that care navigators and case managers can use to track patients and communicate with post-acute care providers. Winning technologies will likely start emerging in 2017.
First mover advantage. Having participated in the voluntary Bundled Payments for Care Improvement (BPCI) initiative of CMS for two years, Hackensack University Medical Center already has many of the necessary foundational elements in place for CJR. Joint replacement surgeons staffing the 900-bed, not-for-profit research and teaching hospital were largely responsible for instituting major reforms—including better management of postoperative pain, patient expectations, and the cost of devices and disposables. Although HackensackUMC has long been a center of excellence for hips and knees, BPCI was a wake-up call. In January 2013, a disproportionately high number of patients were going to a SNF or acute rehab following surgery—upwards of 87 percent—and typically staying there for 21 to 25 days.
Fast forward to 2016. Only about one-third of total joint patients are going to post-acute care. And among those who really need to be there, stays are three times shorter. Transparency with surgeons about the utilization and cost of post-acute care was crucial, and for two years the sharing happened at bi-weekly "Operation Stride" meetings also attended by nurses, case managers, preferred post-acute providers and, as needed, anesthesia and pain management specialists. By standardizing on a robust multimodal technique, the vast majority of patients are out of bed and in a chair, if not walking, the day of surgery. Previously, when patients received opiates intravenously, the side effects (dizziness and nausea) routinely delayed postoperative early mobilization.
The hiring of two advanced practice nurses, and a nurse navigator, was invaluable to the shift in both discharge disposition and quicker returns home from SNFs. Starting the day a procedure gets scheduled, the nurses educate patients about the surgery and manage their recovery expectations using materials (including a slide show) co-developed with surgeons as well as Q&As with patients once they're on the floor. A core curriculum was possible because surgeons were willing to give up their pet preferences, entirely eliminating the variation (patient to patient) in terms of pain management and physical therapy orders. This has all positively impacted HCAHPS scores on orthopedic nursing floors, which are now among the highest in the hospital.
Ironically, it could be difficult to avoid financial penalties under CJR next year since target prices set by CMS will be based on facility-specific historical reimbursement averages. However, the organization should be well positioned to receive reconciliation payments in subsequent years when target prices become more regionally (and ultimately solely) based on regional averages.
Redefining operational excellence. As many organizations with bundled payment experience can attest, providing patient care that is both appropriate and fiscally responsible requires an entirely new type of operational excellence, including:
• A value-focused culture. The odds of succeeding under CJR or any other value-based payment model are higher for organizations that are wholly focused on providing care that is evidence-based, team-led and patient-focused—and the positive ripple effects will be felt by patient groups well beyond those getting a joint replaced.
• Better understanding and managing costs. Bundled payments have exposed the aggressive coding habits of providers who for years have been encouraged by hospitals to document suspected conditions (versus patient symptoms) that at discharge may no longer be valid. Under CJR, this practice will still improve a facility's fee-for-service payment but could also inflate its complication rate, putting reconciliation payments in jeopardy. Best practice is to aim for coding accuracy. Organizations also need to weigh the value of longer hospital stays in minimizing SNF placements, taking into account the opportunity cost in terms of the diversion of other patients for the lack of an available bed. Since CJR maintains patient choice when it comes to post-acute care, plan to build relationships with all of those providers in your service area and educate them about the patients you're sending them, and your communication and reporting expectations. They are staffed largely by LPNs and aides with limited clinical expertise and responsible for many patient populations beyond those getting a new joint.
• Negotiating with suppliers as a united front. Hospital administrators and physicians must approach supplier reps with the singular message that market share will be won by better quality implants at a lower price point. On behalf of its 1,400 hospital members, HealthTrust is now partnered with more than 130 physician advisors to use clinical evidence when making contracting decisions and to rationalize the way orthopedic and cardiovascular technology gets utilized. Physicians report that this is giving them access to top-quality products but at a double-digit decrease in cost.
• Navigating patients across their care journey. Care costs will rise unnecessarily if patients and families aren't emotionally and logistically prepared to go home, including the time of day discharge will happen. Many providers think of the post-surgical period as the starting point for care navigation—via a nurse or technology—but the work ideally begins in the preoperative phase with patient education, expectation setting, and risk stratification to predict and plan for a patient's discharge disposition. This more holistic approach, triggered before an "episode" officially begins, reduces the amount of care navigation resources consumed on the back end—and helps prevent unnecessary patient stopovers in a post-acute facility. By focusing on the two weeks leading up to an admission, the UAMC Medical Center in Little Rock, Arkansas, is now able to discharge home 94 percent of its total joint patients, reports orthopedic surgeon C. Lowry Barnes, M.D.
• Capturing patient-reported outcomes (PROs). The survey tools allowed under CJR for the collection of PROs are all in widespread use and relatively short (10 to 12 questions), so as not to be overly burdensome for patients to complete. The survey tools, while imperfect, are good enough to be mined for improvement opportunities. Hospitals capturing the information for 270 days postop via email or phone need to plan on hiring an extra FTE or two, as well as be cognizant of HIPAA issues. Data collection technology can eliminate the added labor costs, but the tool needs to be certified HIPAA-compliant, which will be a challenge for providers using a homegrown system. The extra two points available to hospitals that opt to collect PROs may not sound like much, but it can be worthwhile if it nudges them from the "good" to the "excellent" category because CMS will lop off fewer dollars per episode. For hospitals two points shy of the "acceptable" category where reconciliation payments kick in, a great deal of cash may be at stake. Keep in mind that CMS will be going public with these outcomes. Hospitals without any data to show aren't going to look good in markets where all of their competitors have opted into reporting. Additionally, CMS intends to create a performance metric around PROs in the future that will be tied to payment. Hospitals not collecting the data won't know where they stand or what needs improving and, by the time they do, may have already lost market share. Data in HealthTrust's InVivoLink registry indicate PRO scores for joint replacement can vary significantly, suggesting they could be an important differentiator for the higher performers.
• Standardizing care. An enormous number of clinical pathways exist for hip and knee replacements and they often differ practice to practice and, in some cases, surgeon to surgeon. In terms of patient outcomes at the facility level, standardizing and coordinating care has time and again proven to be better than physicians following individual protocols, leaving nurses and other clinicians to manage dozens of different approaches to the same procedure. Physician engagement is necessary to make this happen. It makes sense to compensate physicians for the time they spend developing a pathway since this will be time spent away from patient care and include some disruption to their established practice patterns. Administrators, even those with medical degrees, typically don't appreciate that learning to use new implants or techniques, or following new care pathways, can be unnerving until new muscle memories have formed. Many physicians would gladly accept "remuneration" for their work on quality improvement initiatives with an investment in research or infrastructure that broadly benefits patients and, ultimately, the hospital and physicians as well. It's the gesture that counts.
Much ado about gainsharing. Hospitals are differentially approaching the gainsharing question, and that runs the gamut from take-it-or-leave-it contractual agreements carefully crafted by a corporate decision-making center to inaction over concerns about the ethical appropriateness of the tactic for procedures where physicians have a limited role in long-term disease prevention and management. In the best of circumstances, gainsharing contracts are not easily crafted due to a variety of legal and regulatory issues, and that's in addition to decision-making about how to split profits and who should participate. Negotiating deals on a physician-by-physician basis—which is what most doctors would prefer—is overly cumbersome for all but the smallest facilities where the money involved is probably not worth the effort.
The fact that CMS has given control of the bundle to hospitals, along with all the financial risk, means they must somehow engage the surgeons who have greater influence on important decisions along the care path. For hospitals like HackensackUMC with a largely voluntary medical staff, it is viewed as a convenient and effective way to create alignment—and offset time spent away from their clinical practice to work on developing protocols and procedures.
But overall, gainsharing is playing a much smaller role in CJR than originally predicted. Even large IDNs are playing it safe by selectively gainsharing with physicians already recognized as their top performers, avoiding the physician relations debacle that might ensue should quality not improve after concerted effort—resulting in payments not being made as promised. Consequently, it may be a few years before we have enough experience under our belt to suggest how gainsharing deals ought to be structured.
Next up: cardiac bundles. As CMS made clear in July, it has big plans for bundles. In addition to expanding CJR to include femur repairs without hip replacement, two new cardiac bundles are on the way next year—for acute myocardial infarction (AMI, or heart attack) and coronary artery bypass graft (CABG) surgery—which will impact a much broader population of patients across 98 markets, and measure the effect of greater care coordination and intensive cardiac rehabilitation services. Although the basic parameters are remarkably similar to those of CJR, the clinical standardization opportunities are likely to be far greater in terms of which devices get implanted (based on appropriate use criteria) and, to a lesser degree, how many per patient (clinical judgment call). Even among the largest, most advanced IDNs, variability in treatment approach can range anywhere from 25 to 50 percent.
Cardiovascular and orthopedic programs alike have a head start on bundles in that they've dramatically minimized the role of supplier reps in the OR over the last decade. Hospital-based rules and policies limit their access to physicians, and surgeons themselves are much savvier about implant costs. CABG procedures, a target of CMS payment experimentation since the 1990s, is for the most part already bundled (albeit for shorter episodes). Standardization efforts are also well underway at many organizations. At affiliates of LifePoint Health, physicians are leading the charge with standardization initiatives that include the data sets used to measure facility performance, medications used in the cath lab and best practice protocols that get deployed across 30 hospitals with cardiovascular programs.
Until the final directive on the cardiac bundles is issued (expected on Nov. 1), hospitals won't know what target price they'll be aiming to hit—or even if they'll be among the 15 to 20 percent of facilities CMS says will need to significantly alter their cost behavior. But if they're not doing so already, organizations ought to be mining all the data in cardiology registries for care improvement opportunities around stents, pacemakers and defibrillators. One of the more challenging areas will be controlling procedural variability related to technology introductions (most recently for transcatheter valve replacement) by funneling new medical devices through the same intake funnel. For larger IDNs, that may require multiple approval channels based on services performed by a particular hospital. Facilities in more rural markets, where cardiologists often double as primary care providers, will have the advantage when it comes to care coordination.
Since the new bundles apply to a universe of patients who tend to have multiple chronic conditions, a word of caution: CMS will be paying attention to what happens when an episode terminates to be sure providers aren't delaying care simply to keep their costs in check. If a patient needs another pulmonary function test or a second angioplasty, hospitals could be asking for trouble by arbitrarily waiting until right after the 90-day mark.
The arrival of cardiac bundles will accelerate what is already happening in markets impacted by CJR—laser focus on the post-acute space—especially with the continued push to do surgeries on an outpatient basis. Which facilities will be their preferred providers? How will they gauge which are better than others? How will they promote collaboration across longer episodes of care, including post-acute protocols with triggers for when a patient is ready to move out of a hospital? For cardiovascular patients, at least half of whom are Medicare beneficiaries, post-acute care is typically a good and necessary step in their recovery.
Bundled payments may ultimately do exactly what CMS intends—enable better care at lower cost. For many cardiothoracic surgeons, the most revolutionary feature of bundles will be data transparency around cost, allowing them to start talking about overall value. In consistently delivering it, they're likely to gain considerable influence on a hospital's broader strategic direction.
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