At the Forefront of Bundled Payments & Clinical Quality: Connecticut Joint Replacement Institute

The Connecticut Joint Replacement Institute at Saint Francis Hospital and Medical Center in Hartford, Conn., was founded in 2007 and has performed over 17,000 procedures. The center is nationally recognized as a top five hospital in the nation for total hip and total knee replacements and the only hospital recognized in both categories by Consumer Reports.

Schutzer"We have a unique co-management arrangement between the physicians and hospital," says Steven Schutzer, MD, Medical Director of the Connecticut Joint Replacement Institute. "The physicians have a contractual responsibility to improve quality, patient satisfaction and outcomes without financial incentives. We've had a number of physician-led initiatives — including bundled payments — that have helped propel us to the top of the pack."

The bundled payment program started five years ago when physician leadership became interested in medical tourism; they noticed people were going to India and Malaysia for their total joint replacements and felt they potentially could cater to those patients.

"After two years of experience, we had access to clean credible data in terms of costs, risks and readmissions," says Dr. Schutzer. "We were in a good place to look toward bundling including assumption of postoperative risk. At the time, we didn't know where it would go and the process to implement the program took about a year."

The bundle was negotiated between the surgeons and anesthesiologists — both for-profit groups — and the hospital — a non-profit organization. There were some challenges with this arrangement, and involvement of an experienced healthcare attorney was necessary to coordinate the hospital, physician and anesthesia fees into a comprehensive package for patients.

"The most important element was creating the transparency between the three groups," says Maureen Geary, Program Manager of CJRI. "We were able to work together and then take our bundled program to a variety of providers. It has been challenging to align the insurers and employers to assume a shared risk, integrated bundled payment model. However, we were able to sign the first contract in the state of Connecticut for a bundled payment. It was a huge undertaking."

Dr. Schutzer and his colleagues initially assumed working with payers would be easy — "It's seems easier to cut one check than several for care" — but the concept still hasn't caught on widely in the payer community. The team met with private payers several times to show that their prices were lower and that the physicians and the hospital were willing to accept risk. Despite this, the interest is still surprisingly low.

The Connecticut Joint Replacement Institute is currently under contract with ConnectiCare (a state-wide commercial payer) for bundled payments and can also offer bundled payments to individual, self-pay patients as well. The program is still relatively new, but interest will likely increase in the future.

Dr. Schutzer is nationally recognized for his work on bundled payments. Most recently, he presented "the CJRI Value Based Journey" at the Washington, D.C., American Academy of Orthopaedic Surgeons (AAOS) annual meeting.  There were several discussions about self-funded employer groups and price transparency.

"I think bundled payments are heating up as a preferable payment model for total joint replacements," says Dr. Schutzer. "This is being fueled primarily by the large, self-funded employer groups, and, more recently, the payer community."

In order to support a bundled payment program, the Connecticut Joint Replacement Institute has had to strive for continual process improvement. From the beginning, CJRI leaders had the vision to establish a registry to collect patient information and outcomes. This registry has evolved to one of the largest in the nation and is, "our principal vehicle that drives continued quality improvement, patient safety and outstanding clinical outcomes for our patients while providing the tools to run an efficient and profitable business," says Dr. Schutzer.  "This data allows us to benchmark against hospitals at both the local and national levels."

In March 2014, CJRI was recommended for ISO:9001 certification. ISO certification is the mechanism to sustain quality and process improvement. Typically this certification is for the manufacturing world, but with an increased emphasis on standardizing approaches in healthcare, many hospitals are transitioning from the traditional regulatory accreditations to additionally obtaining the ISO certification.   

Stephanie Kelly"After a three year trek, we are very proud of this achievement," says Ms. Stephanie Kelly, BSN Executive Director of CJRI. "We are one of the only hospitals in New England to achieve this certification. The results of this hard work are displayed in our numerous accolades and Press Ganey scores that are highest in the state. "

The Connecticut Joint Replacement Institute continues to be one the nation's leaders for joint replacement surgery and on the forefront of the Healthcare Value Agenda.  The Institute will continue to focus on reducing waste and associate healthcare costs.

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