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POSTED July 19, 2017

Getting Ready for the CMS Proposal for Outpatient Joint Replacement

What's going on?

Last Thursday, July 13th, CMS released a proposal that will allow Medicare to reimburse for total knee replacement procedures in an outpatient setting (currently Total Knee Replacement is on the inpatient-only list). If the proposal is finalized, starting January 2018, Medicare will pay for total knee replacements (total hip replacements currently open for public comment) in Ambulatory Surgical Centers (ASCs).

 

Why is this happening?

Outpatient Medicare coverage should not come as a surprise. In July 2016, CMS submitted a request for public comment to remove TKA’s from its inpatient-only list. Since being added to the list in 2000, developments in Arthroplasty procedures and postoperative care have dramatically reduced complications and variability, including average length of stay from 4.6 days to just 2.8 days in 2016. In many leading centers around the country (many of whom are Force clients), same-day or next-day discharge has become the norm.

 

 

What impact will it have?

The implementation of this proposal will disrupt the market by raising the level of competition between facilities by further fragmenting the market, and putting downward pressure on costs for an entire episode of care (outpatient fees are 25-40% cheaper than inpatient). Sg2 healthcare analytics and consulting estimates 52% of primary knee replacements will be performed in an outpatient setting by 2026, likely to significantly reduce overall spending on TKA episodes.

 

A common concern expressed by many is the effect the proposal might have on existing CMS payment methods – CJR and BPCI. After stressing so much importance on bundled care in inpatient settings, does it make sense for CMS to now drive volume out of the hospital? Bundles depend largely on target prices based on historical costs. Since outpatient procedures generally show improved efficiency and cost reduction, target pricing adjustment is likely – otherwise, do not expect substantial changes in bundled payment models.

 

 

What are stakeholders likely to do about it?

In an industry where players are historically reluctant to change, there will most likely be initial resistance to the proposal. However, as the probable becomes inevitable, surgeons who perform a high-volume of TKA procedures will have broader alignment alternatives – hospitals and ASC’s. Providers will act quickly and decisively to preserve TJA profit centers and physician relationships by discussing co-management and employment opportunities, while also improving physician experience.

 

Without proper incentives, surgeons will happily depart from hospital settings to pursue investment in ASC’s. It’s no surprise, with Dr. Tom Price (Orthopaedic Surgeon) at the helm of CMS, that this proposal gives more control to physicians. Now more than ever, it is essential to look towards ways to improve physician experience by any means necessary. If hospitals choose to forgo formal ways of aligning with surgeons, they must be open to adding more flexibility, better facilities, and superior technology to their system of care.


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POSTED June 26, 2017

Bundled payments aren’t going anywhere -- the time to transition is now

As of March 2017, CMS announced they are postponing the initialization and expansion of several mandatory bundled payment methods, including the extension of the CJR model -- already applied to 67 U.S. regions -- and initiatives for hip fractures (SHFFT) and cardiac care. In the meantime, these delays should not deter health centers from consolidating systems and ideas to scale -- the time to transition is now!

 

Let us first clear up any doubt about the future of bundled payment cast by the Trump administration’s attempts to repeal the ACA. The American Journal of Managed Care states, “if the coverage elements of the Affordable Care Act (ACA) are repealed, payment reform would move forward under the Trump administration, in part because Republicans voted overwhelmingly with Democrats for the Medicare Access and CHIP Reauthorization Act (MACRA).” Yes, the delays are because of an executive order halting new rules, and yes, HHS Secretary, Tom Price, is strongly against mandatory payment methods, but there is still overwhelming popularity of healthcare payment reform and it starts with the CMS initiatives.

 

The real reason for delays

Healthcare reform does not happen overnight. According to the interim rule set in place, CMS, and other participating organizations need time to “modify the policy if modifications are warranted, and to ensure that in such a case participants have a clear understanding of the governing rules.” Providers also need time to appropriately prepare for the changes, so they may be fully engaged in the new program. Speculators predict a January 2018 start date to align with the calendar year and annual financial reporting.

 

The importance of getting ahead

Although these programs have yet to take their full effect, US health care has made strides towards consistency and standardization over the past decade in an effort to bring down skyrocketing costs. As it stands, the price tag for the care of an increasingly aging American population is unmanageable. Scaling is a necessity. Programs such as BPCI have shown that bundled payments are a solution that works for all stakeholders. As CMS leads the trend through CJR, other payers are following suit. The organizations that are going to come out of this transition ahead, are preparing now.

 

It’s becoming clear that delaying the expansion of CJR and other bundled payment methods does not mean wiping them out altogether. From countless ‘trials’ we can see value-based care as, not only a preferred method but a necessity. For providers, figuring out ways to scale accordingly -- reconstructing care networks, integrating new tech, etc. -- runs parallel with success in the inevitable progression towards bundled payment.


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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.

 


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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.


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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


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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.  


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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


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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.”


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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.


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