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POSTED September 6, 2016

Expansion of bundled care payment models to include Cardiac and Maternity Service Lines

As preliminary findings continue to support bundle payment schemes for Orthopaedic procedures such as TKA and THA, the Center for Medicare Services (CMS), alongside thought leaders, are designing plans for their own take on this value-based reimbursement model. Findings suggest that bundles improve quality of care and patient reported outcomes, while creating significant savings for the health system.

As the US healthcare system continues to visualize care as a continuum rather than disparate events, bundle payment expansion plans have been passed by CMS. Proposals for hip fracture and cardiac procedures such as bypass surgery have been published, and plans have been discussed for maternity care and mammography. The goal of expansion is to hold providers more accountable for the quality and coordination of the services they provide, improve the value of care, while decreasing costs. The inclusion of cardiac care and hip fractures in bundled payment models would be the first use of this structure in emergency surgery as opposed to the current use in elective scheduled surgery situations.

According to the Agency for Healthcare Research and Quality (AHRQ), the most common types of procedures performed during hospitalizations in 2010 were associated with maternal and newborn stays or cardiovascular and musculoskeletal procedures.Due to the large scope of these procedures, changing the model across all three will have a huge impact on national costs.

Maternal mortality rates have increased significantly over the last 20 years in the United States due to obesity-related complications such as hypertension and diabetes, the increase in the number of c-section births (1 in 3 US mothers), a lack of access to affordable, quality health care, and more women giving birth at an older age.  This rate has more than doubled since 1987, reaching 17.8 deaths of mothers per 1,000,000 live births in 2011. Maternity care, when defined as an episode of care, ranging from prenatal care, labor and childbirth, to postpartum follow up appointments is a prime candidate for quality improvement through bundled payments. A recent white paper on clinical episode payment models for maternity care, argued that episode-based bundled payments could lead to a higher percentage of babies born at healthy weights, better recovery processes among mothers, and healthier infants at birth (HCP-LAN, 2016).  A pay for performance reimbursement model will put the focus on quality improvements. Bundled payments for maternity care could decrease the rate of unnecessary and expensive c-section’s, reduce pre-term rates to non-elective (only medically indicated), reduce infant mortality, reduce maternal mortality, and reduce ethnic and racial disparities by streamlining care.

Although joint replacement surgeries and maternity care offer a similar episode of care model (pre-op to post-op), it will be interesting to see how this model is adapted to more trauma based procedures such as hip fracture and heart attack response. The Department of Health & Human Services proposed a new model for mandatory bundled payment for heart attack care (AMI) and cardiac bypass surgery (CABG). With this proposed ruling, the hospital in which a Medicare patient is admitted for heart attack care or bypass surgery would be accountable for the cost and quality of care provided to the beneficiary during the inpatient stay and for 90 days after discharge. This model would reward hospitals that work together with physicians and providers to avoid complications, prevent hospital readmissions, and speed recovery. With improvements in care coordination, CMS hopes to increase the number of patients who recover in cardiac rehabilitation, which has been shown to reduce readmission rates (and therefore reduce costs). Discharge processes in hospitals need to be restructured to reflect the evidence base. The adoption of bundled payments in cardiac care will allow providers to rethink processes that discharge patients to post-acute care settings. As this ruling is only proposed at the moment, look out for the final ruling in November 2016.



POSTED August 26, 2016

Necessity of Social Support Following a Total Joint Replacement

As patients navigate the complex pre- and post-operative journey of a total joint replacement, they can experience a wide array of emotions. Pre-operatively, the patient is inundated with complicated information regarding how to prepare for surgery as well as what to expect following the operation. Anxiety around expectations for recovery prevail. Post-operatively, a patient’s emotional needs become more tangible as they begin to utilize their new joint through therapeutic exercises and mobility. The addition of a friend or family member stepping into the role of the patient’s care partner can significantly impact feelings of support as well as postoperative outcomes.

Care partners are a source of strong social support to patients throughout their episode of care. Social support provides emotional, informational, and tangible resources that are needed to cope with both small and large scale stressors.  For example, a care partner could express empathy and reassurance, provide pertinent information regarding his or her care plan, or could physically assist a patient with daily tasks that he or she could otherwise not accomplish. In essence, social support is proven to bolster a patient’s feelings of self-efficacy, thereby giving the patient confidence to better handle the ups and downs of his or her recovery.

Not only can social support buffer the stress that naturally coexists with total joint replacement surgeries, but research demonstrates that it leads to positive health effects and better postoperative functional and quality of life outcomes.  A recent study found that care partner support moderated physical limitations and improved knee function in postoperative TKR patients. Additionally, patients who had higher levels of social support were found to have a decreased perception of pain following their surgery.  Lastly, patients who have strong social support have been tied to less utilization of healthcare services over the episode of care period.

While close interpersonal relationships may lead to care partnerships for some patients, others who are more isolated need to seek such support elsewhere. The answer for patients on their own is technology. Whether it be through a healthcare technological platform that allows a provider to track patient progress or an app that provides enhanced accessibility to health care teams, technology allows for transparent and direct communication and support for total joint patients. Personalized, connective technology has proven to enhance feelings of social support by offering a forum for coping, soliciting emotional or informational support, and camaraderie -- allowing patients without care partners to still access a sense of self efficacy.

The countless benefits of care partner involvement and technological solutions for support in total joint replacement patients have strong implications for social support interventions in hospitals. Providing a setting whereby care partners could become more involved in the recovery journey could be a low cost alternative to excess utilization of care. Whether it be through preoperative joint classes, physical therapy sessions, or postoperative assessments, there is a place for care partners in orthopedic care.  

Simultaneously, optimizing technological solutions that provide a forum for support through interaction with providers, nurses, or patient community groups is key for otherwise isolated patients. The involvement of care partners and social support networks not only increases the well-being and quality of life of total joint replacement patients, but contributes to lowered costs in today’s value-based healthcare landscape.


POSTED August 17, 2016

Rethinking Discharge Destination after THA: Evidence Based Change

New research from the Rothman Institute of Orthopaedics indicates that formal physical therapy is not always necessary after undergoing unilateral total hip arthroplasty. Investigation of patient reported outcomes when given outpatient PT vs. a home prescribed exercise program after total hip replacement or reconstruction showed no significant differences in any measured outcomes at 1 month or 6 months post surgery.

Most patients can do physical therapy on their own after total hip replacement”, one of the study’s authors, Dr. Austin of the Rothman Institute explained. This research, he went on to say, “demonstrates how we can more optimally utilize health resources and lower costs.”

This is especially significant given that, as recently as 5-10 years ago, typical patient discharge following a Total Joint Arthroplasty surgery would include an extended stay in a skilled nursing facility (SNF) or acute rehab. Recovery in these facilities has traditionally been considered the “safest” place to recover due to the additional clinical support offered.  Given medical advancements such as smaller incisions, shorter surgery time, fewer restrictions and more modern drugs prescribed -- this is no longer necessary.

A recent study found that the most common cause of unplanned readmission within ninety days of surgery was due to a surgical site infection (SSI). Superficial or deep infections caused 125 (35.9%) of the 348 readmissions within thirty days of surgery. The study also found that readmission was magnified when patients were discharged to inpatient rehabilitation and/or received prolonged hospitalization. Supporting evidence found patients approximately twice as likely (OR = 1.9) to be readmitted to the hospital when discharged to a SNF after Total Hip Arthroplasty.

Providers have since begun discharging patients directly home with outpatient PT prescriptions. But even outpatient PT has it’s drawbacks. Communication between PT clinics and the surgeon’s care team is not smooth, and it’s near impossible for both PTs and Care Team members to know what’s going on with patients in between their visits to the clinic. Plus, outpatient PT can be an expensive out of pocket cost for the patient and can require taking time off work or finding a care partner willing and able to drive patients to PT appointments. According to recent research from The Rothman Institute, this might be unnecessary in many cases. Using a prescribed home recovery program after total hip arthroplasty saved the Rothman Institute an average of $500 per patient while producing a comparable - or superior - patient reported outcome.

The Rothman Institute has been successfully putting this evidence into practice. According to Medicare claims data from The Rothman Orthopaedic Specialty Hospital (ROSH), 81% of joint replacement patients were discharged to self-care (home without services) and only 5.9% of patients were discharged to a subacute rehabilitation facility after surgery. Readmission rates for ROSH patients receiving hip replacements in 2014 were as low as 2.2% - well below 8%, the average readmission rate in the Philadelphia area.

Implementing this shift -- from SNF, to outpatient PT, to at-home recovery programs -- requires new tools to connect patient and provider. Empowering patients by giving them control and agency as well as support in their recovery will decrease readmissions and the cost of care while optimizing outcomes.


*Medicare claims data from Definitive Healthcare


POSTED August 8, 2016

Technology can relieve patient anxiety around surgery

Patients undergoing surgery for joint replacements often suffer from stress and anxiety related to their surgery. One of the biggest challenges that joint replacement patients face is fear: fear of going home alone, fear that that their surgery won’t work, and especially the fear that they may never return to their previous state of life.

This stress physically manifests and has a negative impact on outcomes which “is not only statistically significant, but also clinically relevant.” Studies show that greater levels of fear, anxiety, and general distress before surgery is associated with “longer hospital stays, more postoperative complications, and higher rates of rehospitalization.” Extreme stress in even healthy individuals can lead to many health problems like high blood pressure, heart disease, obesity and diabetes and these health issues are only exacerbated in patients who have already weakened bodies. These high levels of negative emotions in patients recovering from surgeries negatively affect their wound healing, leading to increased risk for infections, complications, longer hospital stays, greater discomfort, and in general, a slower return to the simple activities of daily living.

On the other side of the spectrum, a positive mindset is able to facilitate a faster and more complete recovery with better outcomes. Studies have shown that patients who believe that their surgery will go well will actually recover better with lower rates of rehospitalization, while patients with pessimistic mindsets will do worse in surgery and recovery with higher rates of infection and hospitalization. Most patients are unsure going into surgery. They have a lot of questions and concerns, and not enough avenues to get answers and reassurance. Leading providers are looking for solutions to scale connectivity, and include the patient more deeply in the process of their care. One of the key ways they are solving for disconnected patients is through technology. Through technology, patients can access the information they need to feel informed and in control while staying in constant communication with their care team and caregivers. These technological advances are allowing patients to be able to recover almost anywhere, in environments where they feel safe and comfortable, including their homes.

The ability to be in touch with their healthcare team from anywhere takes away the unnecessary stress patients go through from having to travel to rehab centers or hospitals and takes away the anxiety from being in unfamiliar environments surrounded by strangers. The ability to be in constant communication with their trusted surgeons and nurses lessons the fear patients have that they are doing something wrong and they may not return to their previous state of life and comfort. Tech is now allowing patients to be in charge of their recovery and have the same recovery process at home. 

Tech based healthcare not only allows patients to recover in comfort, but also empowers them, giving patients the power to make their recovery successful. Patients are empowered by knowing they are in their own homes, doing tasks that they have done for years before their injuries. Patients are empowered by knowing they have someone willing to answer any and all questions with the click of a button. Patients are empowered by knowing that their recovery is in their hands. Patients are empowered by understanding how well their recovery is going. An empowered patient is less likely experience fear and anxiety and more likely to experience positive outcomes and a make a complete return to their daily life and activities.  


POSTED June 29, 2016

Patients are ready to embrace technology

As U.S. healthcare shifts to a value-based care model, providers, payors and patients are looking for sustainable solutions to lower hospital costs while improving patient outcomes.  The adoption of innovative mobile health technology is an integral element of the new model. Patients are an underutilized resource in healthcare and their engagement is necessary to succeeding in value-based care. Technology has the ability to transform engagement, by making care convenient and accessible for greater numbers of patients.   

Although some worry that mobile health isn’t accessible for all populations, recent data shows  84.2% of the U.S. population has access to the Internet. Nearly 73% of U.S. adults own a smartphone. Users check their smartphones an average of 150 times per day.  Given the reach of technology, health tech and mobile health has the potential to connect hard to reach patient populations- anytime, anywhere.

 Technology can connect patients to their clinicians and other medical personnel in unprecedented ways. Many health and wellness apps bridge the gap between the patient and the provider through messaging platforms, proving that there is great opportunity to leverage applications to better link patients to their care teams, leading to better care and outcomes.

Through these new tools, patients are empowered in their self-care, with new levels of access to, and interest in their own medical information. And they’re ready to use it . Recent data suggests that nearly 72% of Internet users went online to research information related to their health conditions in the past year.  Additionally, 58% of smartphone users reported that they have downloaded a health app.

However, as patients take advantage of this ability to find out more, there’s a risk that they will find and follow untrustworthy health advice, or that the apps they’re downloading aren’t as clinical as they appear. It’s important for providers to catch up to tech savvy patients and get in control of the way they use technology, to ensure they’re not fed misinformation that could ultimately harm their health.

The opportunity  to improve care through new tools is too big to pass up. Technology has the potential to revolutionize health care, making care more personal, convenient, and ultimately more effective.

Featured image credit: "the world wide web" by frankieleon cc2.0 via flickr


POSTED May 25, 2016

Transformation Needs to be More Than a Buzzword

The CJR bundled payment model started on April 1st but many organizations have been surprisingly slow to adapt. We've heard a lot about how it's “good to be bad” in the first couple years, creating a high episode price target and then banking on quick improvement in the second year of CJR to avoid penalties.

We're not sure that this is the time to try to play the system. The shift calls for deep changes, core transformations that take time, foresight and iteration to play out correctly. And we say that knowing full well what a buzzword transformation has become. There's a difference between transformation and improvement -- improvement is about marginal changes to an inefficient system. Transformation is about reframing the entirety of the system -- everything from the minutiae of daily activities, to the large abstracts of organizational values and goals.

Recently at a New York City Health Business Leaders panel on the changes the New York market will experience as it shifts from volume to value, Niyum Gandhi, EVP and Chief Population Health Officer at Mount Sinai Health System, went into the difference between transformation and improvement, and why it's important to choose the former.

He put it like this: if you were a shipping company in the 1800s and it took 18 days to cross the sea, but a customer wanted it to be 13 days, you would build a faster ship. If the customer wanted 11 days, you would build a faster ship. If a customer wanted 8 hours? Now we're talking planes.

“Yes we need to see improvement” said Mr. Gandhi. “But we also need to be building planes.”

The question is what does a plane look like?  And then the question is, how do you turn an armada into an air force. And he pointed out that this transformation is even trickier than the analogy. How do you change a boat into a plane while it's moving? We don't get to stop and start from scratch. Leading organizations are tackling full scale redesigns as their practices are moving.

Gandhi explained that as they take a practice and try to turn it upside down there are steel cables of functionality holding it into place. He then has to decide which cables to snip.  That's why Gandhi has pulled together an interdisciplinary team of UX designers, industrial engineers and more to go about the work to turning their system inside out, and shaking off the excess weight. 

Gandhi and his team are moving decisively and they're not looking back. They understand that to be successful in value organizations need to move now and they need to move quickly from fee-for service to value-based care -- there isn’t room to hang around in the middle.  

“The math on one end works and the math on the other end works, but the math in the middle doesn't,” said Gandhi. “That's why we're moving fast. That's why we're burning ships.”


POSTED May 19, 2016

Technology Supports Caregivers, The Unsung Heroes of Healthcare

Technology is key to value-based change. It’s the only way to have a scalable, 24x7 relationship and interface with the patient.  A higher educated and more confident patient will have a stronger outcome. We often hear concerns about engaging seniors who aren't comfortable with digital interfaces, but in a population with an average age of 66, we see an 85+% opt in rate, with 70+% frequently messaging. A large part of this success has to do with caregivers who are assisting the patient throughout their episode of care.

According to Steve Nelson, CEO of UnitedHealthcare’s Medicare business, “Family caregivers are the unsung heroes of our healthcare system, and supporting them is a tremendous challenge.” We’ve discovered 71% of caregivers would prefer to assist their loved ones with technology, but less than 10% have access to useful platforms. Technology keeps these caregivers and patients connected and educated, allowing for seamless patient-provider communication throughout the episode.

Many patients are able to recover in their home, which is the safest place for them to be, and which 90% prefer. Results are also showing improved outcomes -- fewer readmissions and better function while bringing recovery in the home, leading to a happier and healthier patient.

The challenge is that in typical episode of care, patients’ and caregivers’ spend very little time with their surgeon and care team. 99% of recovery is spent outside the traditional system. Information provided to patients is often not absorbed, and what is digested is frequently misinterpreted.  40-80% of information a doctor gives their patient in conversation is “immediately” forgotten. The vast amount of information conveyed in paper format is equally ineffective. As a result, success in a bundled payment world requires a transformation of the patient and provider relationship.

A key tool in scaling the relationship is video. Video reduces anxiety in a similar way to interpersonal conversations, which makes it the next best thing to having the provider in the room with the patients. Many physicians are using the medium to communicate essential information with their patients -- which the patients can then turn around and use to communicate more effectively with their caregivers. Recorded information makes sure the caregiver is as in the loop as possible. When caregivers are as educated as possible, recovery is smoother.

Technology continues to reinvent the way care is delivered and is an inextricable part of the future of health care. It’s understood technology is not a stand alone solution, but it’s a solution many patients and their caregivers want and need. Together we’re broadening the opportunity for successful episode management via user friendly technology, while educating more confident patients with the right information, at the right time, in the right format.


POSTED May 3, 2016

Innovator Spotlight: Dr. Rich Iorio, Dr. Joe Bosco, Lorraine Hutzler

The Comprehensive Care for Joint Replacement launched April 1st, mandating bundled payments for Lower Extremity Joint Replacement at 800+ hospitals in 67 MSAs. For many providers who didn't participate in the optional BPCI program, there is a knowledge gap surrounding bundles and navigating the shift to value based care.

Dr. Rich Iorio, Dr. Joe Bosco, and Lorraine Hutzler are looking to fill that gap, with the "aim to improve the delivery of Orthopaedic services in a value-based care paradigm." They have all experienced success with the bundle. Now they want to share what worked for them. They’re working with other organizations to help them make the difficult shift to value.

"This program seeks to improve healthcare delivery, inclusive of the patient experience while reducing costs and maintaining outcomes," explains Dr. Iorio. "We have a lot of knowledge and expertise to share with like-minded value-driven organizations and partners. We saw an opportunity to bring our Value Based Care improvement expertise to other hospitals."

The opportunity

CJR and other bundle programs present high performers with an opportunity for market differentiation and shared savings. In order to take full advantage, providers must control of the entire episode of care -- from pre-op optimization through the 90-day recovery period.

"Home health, physical therapy, visiting nurses and post-acute facilities all should be bundled in order to make costs more predictable and eliminate the excess utilization in the system," says Iorio.

Looking towards the future, the value based healthcare movement is going to go beyond surgical procedures. Iorio anticipates that "we will move to population management based care.  Episodes of care for arthritis will be decades in length.  We will have disease modifying interventions.  TJA will be less prevalent but joint preserving procedures will be more prevalent.  Improving health status will be a key to preventing the progression of OA."

The game plan

Given the variation in post-acute cost, "choosing the 90-day option [in BPCI] presented the greatest opportunity for cost savings." But that doesn’t mean that pre-op isn’t critical. Iorio remarked that without robust preop optimization "even intensive care management can be ineffective at preventing readmission."

In order to be successful with this, "hospitals and surgeons must align their goals and work together." Surgeons and their care teams have the most direct impact on patient behavior, their expectations and outcomes. According to Iorio, surgeons need to be "involved from the start as the champion of the project and the hospital must reward the surgeons for behavior modification and practice changes that improve the performance of the TJA episode and create value."

As physicians and the hospital work together to create and adhere to best practices "transparency of performance, quality metrics and resource availability is critical” in creating accountability and benchmarks for success. And in the process of alignment, Iorio says “Data is king.”

Technology is an essential part of episode of care management and creating an interface with the patient when they're own their own, which makes up more than 2,300 hours in a 90-day bundle. Tech's ability to scale the patient and provider relationship makes it an inextricable part of building a value-based future. Especially for organizations with limited resources.

"For large, well-resourced health care institutions most of the issues concerned with managing patients in a bundled environment involve FTE’s and human solutions which are quite costly," says Iorio.  "For smaller, less well-resourced institutions, technology apportioned on a per patient basis is a much more cost efficient way of delivering the services necessary to make value based care successful."

The effect

Their previous success implementing care redesign for bundles speaks for itself. The hospital, its surgeons and its patients have had better outcomes – clinically and financially.  As Iorio puts it: "Cost has gone down, quality has gone up.  Value has been created."


POSTED April 28, 2016

Success in the Bundle Lies in Gainsharing

The mandated bundled payment program, CJR launched this month, which means hospitals in 67 MSAs will be redoubling focus on improving patient outcomes, increasing system efficiency, and reducing overall cost of care. Their greatest resource in making the shift to bundled care will be their surgeons. Organizations who are able to successfully align their interests and programs of care with their surgeons, will in turn be successful in creating valuable care. Gainsharing is the way to go about this. While this may once have been shady business, CJR has made it clearly legal in the bundle.

The benefits of this practice seem pretty clear cut: The necessary changes to be successful in the new musculoskeletal landscape are going to be difficult, sharing the profits of that change with key stakeholders is a strong way to ensure that everyone gets on board.

It’s unlikely that hospitals will be able to make the necessary shifts to be successful with the bundle without aligning with surgeons through gainsharing.

Surgeons are the most powerful figure in a patient’s episode of care. Surgeons and their care teams prescribe evidence-based care plans, modify risk factors and manage patient expectations around discharge destination and recovery. Success in these areas define success in the bundle. It’s essential that surgeons quarterback their patient’s entire episode, both inside and outside the hospital.

Technological innovations, increase in choice implant prices, and the transition from outpatient surgical centers to ambulatory care centers, have created a tremendous amount of variation in episode cost. A lot of that variation comes down to the surgeons, who have the power to choose the tools they think are most likely to lead to success. Sometimes those tools come at a very high cost, but they don’t always lead to higher outcomes.

Hospitals who are able to work with their surgeons to create a set of best practices that are both clinically and financially sound will be well on their way to a strong episode of care. But without giving surgeons a strong reason to participate (without creating a gainsharing program) the chance of coming to consensus on valuable best practices is slim.

That being said, gainsharing fosters a team-based mentality that cultivates continuous improvement. By prioritizing integrated care and concentrating on high quality patient centric care and financial efficiency, hospitals and physicians will be able to collaborate in a way that ensures sustainable success for the future.