the joint replacement bundle: implications for patients and acute pain services

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Joint Replacement Bundle:Implications for Patients and

Acute Pain ServicesEdward R. Mariano, M.D., M.A.S.

Professor of Anesthesiology, Perioperative & Pain MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

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Disclosures

No current financial disclosures (past 12 months)

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Healthcare Is Changing

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Let’s Review the Facts

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FACT: U.S. is LastAccessEquityOutcomes

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FACT: “The Triple Aim”

Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131

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Kurtz S, et al. JBJS 2007 Apr;89(4):780

FACT: Arthroplasties Are Increasing

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Kurtz S, et al. JBJS 2007 Apr;89(4):780

FACT: Arthroplasties Are Increasing

Now Over 1,000,000 THA and TKA Cases Annually

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FACT: MACRA Passed in 2015

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Overview

Introduction to Bundled Payment

Comprehensive Care for Joint Replacement

Opportunities for the Acute Pain Service

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What Is Bundled Payment?

“[A model of care] which link payments for the multiple services beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.”

https://innovation.cms.gov/initiatives/bundled-payments/

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What Is Bundled Payment?

http://www.kpmginfo.com/healthcare/PDF/bundled-payments-for-patients-providers.pdf

Bundled Payment Care Improvement (BPCI) InitiativeBegan in 2013 (Voluntary)

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BPCI Initiative for Arthroplasty

Model 1: inpatient stay only (phased out)

Models 2 and 3: retrospective payment against targeted price based on 3-year institutional averages

– Model 2: inpatient hospital stay + acute postoperative 90-day period

– Model 3: only acute 90-day postoperative period

Model 4: prospective payment modelhttps://innovation.cms.gov/initiatives/bundled-payments/Siddiqui, et al. J Arthoplasty 2017;32:2590

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Positives

Development of clinical pathways

Increased patient education

Decreased length of stay

Decreased admission to rehab

Decreased cost of care

Decreased readmissions

Negatives

Shared risk by providers

Unanticipated infrastructure costs (e.g., EMR, dashboards)

Unanticipated staffing costs (e.g., clinical care coordinators)

https://innovation.cms.gov/initiatives/bundled-payments/Siddiqui, et al. J Arthoplasty 2017;32:2590

BPCI Initiative for Arthroplasty

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Overview




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Comprehensive Carefor Joint Replacement (CCJR)

https://innovation.cms.gov/initiatives/cjr

Started in 2016 (Not Voluntary)

Implemented in “67 geographic areas, defined by metropolitan statistical areas (MSAs). MSAs are counties associated with a core urban area that has a population of at least 50,000.”

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Comprehensive Carefor Joint Replacement (CCJR)

https://innovation.cms.gov/initiatives/cjrhttps://qpp.cms.gov/apms/overview

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Comprehensive Care

From 67 mandatory metro areas (initial)

33 become voluntary

34 stay mandatory unless rural or low-volume (<20 LEJR during 3-yr period)

Final rule pending

for Joint Replacement (CCJR)

https://innovation.cms.gov/initiatives/cjrFederal Register Vol. 82, No. 158, Aug. 17, 2017

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Overview




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Perioperative Surgical Home (PSH)

“a patient-centered, physician anesthesiologist-led, multidisciplinary team-

based practice model that coordinates surgical patient care throughout the

continuum from the decision to pursue surgery through convalescence.

Mariano, et al. A&A 2015;120:1163Kain, et al. A&A 2014;118:1126

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Elements of PSH

PSH: Comprehensive Literature Review, www.asahq.org/psh

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Mariano, Walters, Kim, Kain. A&A 2015;120:1163Walters, Mariano, Clark. Pain Med 2015;16:1666.

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Pain and Readmissions

Hernandez-Boussard, et al. Ann Surg 2017;266:516

Postoperative pain trajectories identify populations at risk for30-day readmissions and ED visits

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“Unlike current questions, which ask about the efficacy of pain treatment, the new set will focus on the communication between doctor and patient about pain.”

http://www.nytimes.com/2016/08/05/health/pain-treatment-hospitals-emergency-rooms-surveys.html?_r=0

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Avoid “Never” Events

Federal Register May 3, 2007

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Anesth Clinics 2014;32:853

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Summary

We discussed:

– Introduction to Bundled Payment

– Comprehensive Care for Joint Replacement

– Opportunities for the Acute Pain Service