ConditionBased Bundled Payments Drive Care Redesign to Produce
Condition-Based Bundled Payments Drive Care Redesign to Produce Greater Value for Patients: A Case Study Kevin J. Bozic, MD, MBA Professor and Chair, Department of Surgery and Perioperative Care Dell Medical School at the University of Texas at Austin Senior Institute Associate, Harvard Business School
Burden of Osteoarthritis
Arthritis Treatment Ladder
Focus of Alternative Payment Models
Key Results • 1. 6% reduction in episode spending • Lower inpatient and post-acute care spend • Reduced ALOS and readmissions • Increased discharge to home/self-care • Increased case complexity
Payment Model Drives Delivery System Reform 6 Miller H D Health Aff 2009; 28: 1418 -1428
TJR Bundles Drive Care Coordination Across Acute, Post. Acute Settings 7
What’s Missing from Procedure-Based Bundles?
Evolution of Value-Based Payment Models Management of Arthritis (including risk factor modification) BPCI Future? ACE Demo CJR Close Pre Close Post 15 Days Knee Replacement Surgery 42 Days Further Post Window 90 Days 180 Days
Longitudinal Management of Hip/Knee OA Advanced Imaging Chiropractic HA Injections Primary care physician Non evidence-based, non value-added care Opportunity Gap Treatment of hip or knee arthritis Orthopaedic surgeon
Payment Model Drives Delivery System Reform TJR Bundles Arthritis Bundles 11
Changing the Delivery Model Existing Model Organize by Specialty and Discrete Service Imaging Centers PT/OT Chiropractor Dietician Medication Management Behavioral Health Physician Associate Social Provider Work Nutrition Physical Therapist Orthopaedic Surgeons Primary Care Provider Care Coordinator Hospitals Behavioral Health Risk Modification Core Care Team Shared Resources Pain Management
‘Downstreaming’ Care
Patient Engagement: Activation Measures an individual's propensity to engage in positive health behavior. Skolasky et al (2011) Postoperative Findings Questionnaire P-value Better Pain Relief HOOS/KOOS Pain Score 0. 048 Better Symptom Relief HOOS/KOOS Symptom Score 0. 021 Higher Mental Health Scores SF 12 v 2® <0. 001 Higher Patient Satisfaction Hip & Knee Satisfaction Scale 0. 023 14
Measuring Outcomes That Matter to Patients PATIENT REPORTED Outcomes (PROs) Report of a Patient’s Health Status that comes directly from the patient Role limitations due to physical and emotional problems Physical Functioning General Health Related Quality of Life Mental Health Bodily Pain Energyfatigue Social Functioning
Personalized Shared Decision Making
Using PROs to inform clinical decision making Can Preoperative Patient-Reported Outcome Measures Be Used to Predict Meaningful Improvement in Function after TKA? Knee injury & osteoarthritis outcome score (KOOS) threshold predicts the likelihood of benefit with knee replacement surgery score of 58+ lowers chance of benefit.
Using PROs to inform appropriateness of surgery When mental health scores are layered on top of the joint-specific disability score, a more robust view of whether or not the patient will be helped by joint replacement emerges Mental health measure
Personalized Shared Decision Making
Alternative Payment Models for Hip and Knee OA Start of hip or knee OA care Hip or Knee OA Care Management Care pathway focused on improvement of patient outcomes Up to 12 months episode of care for non-surgical care First E&M visit with a specialist for hip or knee OA trigger the non-surgical case rate Last E&M visit with a specialist for hip or knee OA before surgery trigger a SEPARATE surgical case rate Condition based bundle Evaluation and Management, Exam Room Procedures, Diagnostic Ancillaries, Support Services¹, Treatment Ancillaries, Patient Education² 1. Support Services include DME, immunization/vaccine, etc. (only will be given if it is necessary); 2. Patient education includes service & materials fees, patient’s history, registration, education, etc. Up to 4 months episode of care for surgical care Procedure based bundle Pre-operative care, surgery, post-acute care Time Graduate from the Episode care
Timeline Multistakeholder coalition forms 2020 2019 2018 Multistakeholder conceptual design input Quantitative analysis demonstrates broad opportunity Practices and payers take deeper look at concept and impact Payers begin strategic planning for condition-based payment (e. g. CMMI) Larger multistakeholder group reaffirms commitment to specialty alternative payment model reform
How can AAHKS help? 1. Socialize awareness to members: pivotal time for model design input, member preparation for continued evolution of alternative payment models 2. Join and lead working groups: payment design, quality and outcome measurement (e. g. patient-reported outcomes measurement) 3. Elicit pilot partnerships: identify members eager and ready to assume greater risk and reward by broadening scope of contracts; partner directly with innovative payers
Summary • • • Musculoskeletal disease is prevalent, costly Management of MSK conditions is characterized by variation in treatment approach, outcome, cost SIGNIFICANT opportunity to drive value through care redesign, payment reform Procedure-based bundles will only get us so far Real opportunity lies in redesigning care across the continuum, changing payment incentives through condition-based bundles
Thank You!!
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