Bundled Payments For Care Improvement Research Articles

Is there value in retrospective 90-day bundle payment models for shoulder arthroplasty procedures?

The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative was implemented as part of the Affordable Care Act. We implemented a retrospective payment model 2 for a 90-day total shoulder arthroplasty (TSA) episode to assess the value of TSA BPCI at our private practice. Expenditures and postacute event rates of 132 fee-for-service (FFS) patients who underwent a TSA operation between 2009 and 2012 were compared with 333 BPCI patients who had a TSA operation in 2015. The 90-day postacute events included an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), and home health (HH) admissions and readmissions. Expenditures were converted to 2016 dollars using the Consumer Price Index. Wilcoxon tests and multivariate generalized estimating equation were used to assess independent cost-drivers. The median FFS expenditure was $21,157 (interquartile range, $16,894-$30,748) compared with $17,894 (interquartile range, $15,796-$20,894) for BPCI (P < .0001). The BPCI patients had significantly lower rates of SNF admissions (34% FFS vs. 16% BPCI; P < .001), IRF admissions (3% FFS vs. 0.6% BPCI; P = .05), HH utilization (49% FFS vs. 41% BPCI; P = .05), and readmissions (14% FFS vs. 7% BPCI; P = .01). After controlling for postacute events in the multivariate regression model, we found BPCI had a 4% decrease in expenditures (P = .08). All postacute events were independently associated with higher expenditures. Our private practice implemented cost-containment practices, including clinical guidelines, patient navigators, and a BPCI management team. IRF and SNF utilization and the 90-day readmission rate significantly decreased. As a result, we were able to control the postacute spending, which resulted in decreased costs of performing TSA surgery.

53 - Is There Value in Retrospective 90-Day Bundle Payment Models for Cervical Spine Procedures?

BACKGROUND CONTEXT: The Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative was implemented at our private orthopedic practice in 2015. At that time, we implemented a retrospective payment model 2 for a 90-day episode of care and selected cervical spine and other orthopedic procedures. Under these retrospective payment models, Medicare continues to make fee-for-service (FFS) payments but reconciles the total expenditures for the episode with a bundled payment amount as determined by CMS. A payment or recoupment amount is then made by Medicare reflecting the aggregate expenditures compared to the target price. The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

Society Advocacy Continues to Make Impact Amid Uncertainty

Society Advocacy Continues to Make Impact Amid Uncertainty

Similar Cost Savings of Bundled Payment Initiatives Applied to Lower Extremity Total Joint Arthroplasty Can Be Achieved Applying Both Models 2 and 3

BackgroundIn an effort to control cost and increase value, Medicare is transitioning from fee-for-service to value-based alternative payment models (APMs). The Bundled Payments for Care Improvement (BPCI) initiative represents one such voluntary APM. BPCI offers four different bundling options: model 1 covers all Diagnosis Related Groups (DRGs) and Models 2–4 cover 48 clinical episodes, including 186 separate DRGs.Questions/PurposesThe purpose of this investigation is to analyze and compare the cost savings achieved by two different BPCI program participants, provider A and provider B, enrolled in different models of BPCI (Models 2 and 3) for lower extremity joint replacements (LEJRs).MethodsWe analyzed the BPCI cost savings for Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 (lower extremity joint replacement) of two different BPCI program participants. One (provider A) participated in Model 2 while the other (provider B) participated in Model 3. Retrospective payments were based upon savings generated by decreased actual expenses reconciled against target pricing for the episode of care in Models 2 and 3.ResultsThe Model 2 participant reduced the average cost of all episodes by 18.45%, with all of the savings occurring in the post acute phase. The Model 3 participant reduced episode costs by 16.73%.ConclusionBoth BPCI providers achieved similar cost savings despite participating in different BPCI models. These cost savings all occurred in the post acute setting. The Model 2 provider achieved post acute savings through decreasing overall discharges to institutional post acute care (PAC) providers and decreasing readmissions, while the Model 3 provider decreased costs largely by decreasing the LOS for the institutional PAC providers and decreasing readmissions.

First Year Experience of a Quaternary Medical Center with Heart Failure Bundled Payment

Background: The Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative is an alternative payment model designed to link payments for multiple services received during an episode of care. The goal is to achieve higher quality and greater coordination of care at a lower cost to CMS. Inova Fairfax Hospital joined the BPCI Model 2 program for heart failure effective October 2015, assuming both upside and downside risk for a 90-day episode of care. Cost targets for each of the 3 heart failure MS-DRGs (291–293) were established based on 2009–2012 Medicare spending. Performance improvement initiatives included nurse navigators (inpatient and post-acute), enhanced order sets (ED, hospital, home health), physician documentation education, and skilled nursing facility network development. While our institution achieved cost savings during the first year, we sought to better understand the factors responsible for this success and opportunities for improvement. Methods: Eligible patients likely to be billed to a heart failure MS-DRG, excluding ESRD, were identified at admission and followed for 90 days post discharge. CMS paid claims were analyzed to study episode cost performance compared to baseline, including readmissions, skilled/acute rehab, home health, outpatient procedures, and home infusion therapies. Results: There were 298 episodes of care: 48.7% were billed MS-DRG 291 (high acuity) and 51.3% were billed MS-DRG 292 or 293 (low acuity). We successfully reduced skilled/acute rehab utilization from 30% to 23% and 90-day readmissions from 34% to 31%, achieving a 1% savings from our cost target. Overall, 73% of episodes were breakeven or favorable, with high acuity patients less likely to achieve savings compared to low acuity patients (64% vs 82%) and 7% of episodes exceeded target by a cost of $30,000 or more, with drivers including readmissions, extended skilled/acute rehab stays, elective TAVR, planned ICD implants or replacements, and high cost home infusion therapies. Conclusions: During the first year of participation, cost savings were primarily driven by reductions in skilled/acute rehab utilization and readmissions, while care for high acuity patients was more likely to result in economic losses. Quaternary referral centers participating in BPCI for heart failure are vulnerable to negative cost performance due to providing medically complex care for heart failure patients.

Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality.

The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA). From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control. Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.

Bundled Payments for Care Improvement: Preparing for the Medical Diagnosis-Related Groups.

BACKGROUNDThe Centers for Medicare and Medicaid Services Innovation Center introduced the Bundled Payments for Care Improvement (BPCI) initiative in 2011 as 1 strategy to encourage healthcare organizations and clinicians to improve healthcare delivery for patients, both when they are in the hospital and after they are discharged. Mercy Health Saint Mary’s, a large urban academic medical center, engaged in BPCI primarily with a group of medical diagnosis-related groups (DRGs).OBJECTIVESIn this article, we describe our experience creating a system of response for the diverse people and diagnoses that fall into the medical DRG bundles and specifically identify organizational factors for enabling successful implementation of bundled payments.RESULTSOur experience suggests that interprofessional collaboration enabled program success.CONCLUSIONSAlthough still in its early phases, observations from our program’s strategies and tactics may provide potential insights for organizations considering engagement in the BPCI initiative.

Bundled Payments for Care Improvement: Boom or Bust?

BackgroundAs early implementors of the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative, our private practice sought to compare our readmission rates, post-acute care utilization, and length of stay for the first year under BPCI compared to baseline data. MethodsWe used CMS data to compare total expenditures of all diagnosis-related groups (DRGs). Medicare patients who underwent orthopedic surgery between 2009 and 2012 were defined as non-BPCI (n = 8415) and were compared to Medicare BPCI patients (n = 4757) who had surgery in 2015. Ninety-day post-acute events including inpatient rehabilitation facility or subacute nursing facility admission, home health (HH), and readmissions were analyzed. ResultsThe median expenditure for non-BPCI patients was $22,193 compared to $19,476 for BPCI patients (P < .001). Median post-acute care spend was $6861 for non-BPCI and $5360 for BPCI patients (P < .001). Compared to non-BPCI patients, BPCI patients had a lower rate of subacute nursing facility admissions (non-BPCI 43% vs 37% BPCI; P < .001), inpatient rehabilitation facility admissions (non-BPCI 3% vs 4% BPCI; P = .005), HH (non-BPCI 79% vs 73% BPCI; P < .001), and readmissions (non-BPCI 12% vs 10% BPCI; P = .02). Changes in length of stay for post-acute care were only significant for HH with BPCI patients using a median 12 days and non-BPCI using 24 days. ConclusionThe objective of BPCI was to improve healthcare value. Through substantial efforts both financially and utilization of human resources to contain costs with clinical practice guidelines, patient navigators, and a BPCI management team, the expenditures for CMS were significantly lower for BPCI patients.

Results of a Medicare Bundled Payments for Care Improvement Initiative for Chronic Obstructive Pulmonary Disease Readmissions.

Approximately 20% of Medicare beneficiaries hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) are readmitted within 30 days of discharge. In addition to implementing penalties for excess readmissions, the U.S. Centers for Medicare and Medicaid Services has developed Bundled Payments for Care Improvement (BPCI) initiatives to improve outcomes and control costs. To evaluate whether a comprehensive COPD multidisciplinary intervention focusing on inpatient, transitional, and outpatient care as part of our institution's BPCI participation would reduce 30-day all-cause readmission rates for COPD exacerbations and reduce overall costs. We performed a pre-postintervention study comparing all-cause readmissions and costs after index hospitalization for Medicare-only patients with acute exacerbation of COPD. The primary outcome was the difference in 30-day all-cause readmission rate compared with historical control subjects; secondary outcomes included the 90-day all-cause readmission rate and also health care costs compared with BPCI target prices. Seventy-eight consecutive Medicare patients were prospectively enrolled in the BPCI intervention in 2014 and compared with 109 patients in the historical group from 2012. Patients in BPCI were more likely to receive regular follow-up phone calls, pneumococcal and influenza vaccines, home health care, durable medical equipment, and pulmonary rehabilitation, and to attend pulmonary clinic. There was no difference in all-cause readmission rates at 30 days (BPCI, 12 events [15.4%] vs. non-BPCI, 19 events [17.4%]; P = 0.711), and 90 days (21 [26.9%] vs. 37 [33.9%]; P = 0.306). Compared with BPCI target prices, we incurred 4.3% lower 90-day costs before accounting for significant investment from the health system. A Medicare BPCI intervention did not reduce 30-day all-cause readmission rates or overall costs after hospitalization for acute exacerbation of COPD. Although additional studies enrolling larger numbers of patients at multiple centers may demonstrate the efficacy of our BPCI initiative for COPD readmissions, this is unlikely to be cost effective at any single center.

Episode-Based Payment and Direct Employer Purchasing of Healthcare Services: Recent Bundled Payment Innovations and the Geisinger Health System Experience.

One significant driver of the disjointed healthcare often observed in the United States is the traditional fee-for-service payment model which financially incentivizes the volume of care delivered over the quality and coordination of care. This problem is compounded by the wide, often unwarranted variation in healthcare charges that purchasers of health services encounter for substantially similar episodes of care. The last 10 years have seen many stakeholder organizations begin to experiment with novel financial payment models that strive to obviate many of the challenges inherent in customary quantity-based cost paradigms. The Patient Protection and Affordable Care Act has allowed many care delivery systems to partner with Medicare in episode-based payment programs such as the Bundled Payments for Care Improvement (BPCI) initiative, and in patient-based models such as the Medicare Shared Savings Program. Several employer purchasers of healthcare services are experimenting with innovative payment models to include episode-based bundled rate destination centers of excellence programs and the direct purchasing of accountable care organization services. The Geisinger Health System has over 10 years of experience with episode-based payment bundling coupled with the care delivery reengineering which is integral to its ProvenCare® program. Recent experiences at Geisinger have included participation in BPCI and also partnership with employer-purchasers of healthcare through the Pacific Business Group on Health (representing Walmart, Lowe's, and JetBlue Airways). As the shift towards value-focused care delivery and patient experience progresses forward, bundled payment arrangements and direct purchasing of healthcare will be critical financial drivers in effecting change.

Effect of Risk Acceptance for Bundled Care Payments on Clinical Outcomes in a High-Volume Total Joint Arthroplasty Practice After Implementation of a Standardized Clinical Pathway

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities. MethodsThis practice implemented a standardized CP focused on patient education, managing patient expectations, and maximizing cost outcomes. We retrospectively reviewed all primary total joint arthroplasty patients during the initial 2-year “at risk” period for both BPCI and API and determined discharge disposition, LOS, and readmission rate. ResultsDuring the “at risk” period, the average LOS decreased in our total joint arthroplasty patients and our patients discharged home >94%. Patients within the BPCI group had a decreased discharge to home and decreased readmission rates after total hip arthroplasty, but also tended to be older than both API and nonbundled payment patients. ConclusionWhile participating in the BPCI and API, continued use of a standardized CP in a high-performing, high-volume total joint practice resulted in maintenance of a low-average LOS. In addition, BPCI patients had similar outcomes after total knee arthroplasty, but had decreased rates of discharge to home and readmission after total hip arthroplasty.

BPCI: Everyone Wins, Including the Patient

BackgroundAlternative payment models are becoming increasingly more common with the rising cost of the US health care. Bundled payment programs for elective hip and knee arthroplasty have shown promising results by improved outcomes and significant cost reduction. MethodsAll consecutive total joint arthroplasty with diagnosis-related group (DRG) 469/470 were included in this study. And 1427 episodes from 2009 to 2012 were defined as the baseline group; 461 episodes from October 2013 to September 2014 were defined as the Bundled Payments for Care Improvement (BPCI) group. ResultsBPCI group had a 14% reduction in cost per episode. The average length of stay decreased from 3.81 to 2.57 days. All-cause readmissions within 90 days of surgery decreased from 16% to 10%. The average cost of readmission decreased by 23%. Net Centers for Medicare and Medicaid Services (CMS) reconciliation payment for BPCI initiative participation was $1,012,962.79 for this 12-month study. ConclusionOur participation in the 2013-2014 CMS BPCI initiative for DRG 469/470 led to decreased readmissions and significant cost savings. In this study, minimizing hospital length of stay and discharging patients to home were the most effective strategies to achieve these outcomes.

Abstract TP309: Creating a Crystal Ball: Predicting Successful Rehabilitation for Optimal Discharge Placement

Introduction: In 2014, the Centers for Medicare and Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) program. Our institution is contracted for a 90 day stroke bundle, making us responsible for all Medicare stroke patient costs. Quarterly review of 2015 financial data (DRG 64 &amp; 65) revealed a significant spend occurs in the post-acute care phase. Methods: Detailed analysis and sequencing revealed that of the 40% of patients discharged to an Inpatient Rehab Facility (IRF) 31% were unsuccessful in rehabilitation and instead transitioned to a Skilled Nursing Facility (SNF). Had SNF been initially selected, a cost avoidance of $292,650 would have been appreciated. Conclusion: Involvement in the BPCI program has provided insight into the post-acute care of stroke patients. With the advent of BPCI, institutions will be increasingly held fiscally responsible for post-acute care delivery. Ongoing retrospective chart review and collaboration with Physical Medicine and Rehabilitation colleagues is underway to identify key indicators that would project successful rehabilitation. Analysis will include comparison between those who were successfully discharged home after an IRF stay to those that needed a SNF after an IRF stay. This would provide inpatient teams with strategies for predicting the optimal discharge location for stroke patients.

Abstract WP311: Early Lessons Learned in the Stroke Bundled Payment Experience

Introduction: The Bundled Payments for Care improvement (BPCI) initiative was launched by the Centers for Medicare and Medicaid Services (CMS) in 2014. Our organization contracted for Model 2, making us responsible for all costs associated with index hospital stay plus 90 days post discharge for straight Medicare patients. It was anticipated that we would find opportunity for reduction in readmission rates, which would lead to reduced cost of care. Analysis of Q1 &amp; Q2 2014 data revealed other opportunities. First, cases coded as non-traumatic Subdural Hematoma (SDH) - regardless of readmission - accounted for significant financial deficit. Second, 67% of patients utilized Post-Acute Care (PAC - SNF, acute rehab, home health) at least once and 54% utilized a second PAC. All patients discharged to acute rehab who then transitioned to SNF exceeded the target price for the bundle. Methods: A case review of SDH episodes revealed that many were traumatic but not documented as such. A summary of these cases was presented to providers with recommendations for appropriate wording to ensure appropriate coding. Education was also provided to coders related to BPCI regarding the impact of clarifying traumatic cause of SDH. Protocols for post-acute management were developed with partners in acute rehab &amp; SNF’s in the region and gain-sharing agreements were developed. Partner facilities reviewed each bundled stroke patient for opportunities to reduce post-acute care LOS. Results: Analysis of Q3 2015 demonstrated that the number of SDH cases in the bundle dropped significantly, improving the financial picture six-fold. A reduction in SNF LOS of 25% was appreciated. Conclusion: Stroke is a leading cause of disability in the United States and post-acute care for a 90 day episode carries a prohibitive cost. Accurate documentation and partnering with post-acute facilities does improve the financial position. Ultimately though, post-acute care - not readmissions - is the major driving force for dollars spent in Stroke BPCI.

Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.

Cost of Joint Replacement Using Bundled Payment Models

ImportanceMedicare launched the mandatory Comprehensive Care for Joint Replacement bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles.ObjectiveTo analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC.Design, Setting, and ParticipantsThis observational study followed 3942 total patients with lower extremity joint replacement at Baptist Health System (BHS), which participated in ACE and BPCI.ExposuresLower extremity joint replacement surgery under bundled payment at BHS.Main Outcomes and MeasuresAverage Medicare payments per episode, readmissions, emergency department visits, prolonged length of stay, and hospital savings from changes in internal hospital costs and PAC spending.ResultsOverall, 3942 patients (mean [SD] age, 72.4 [8.4] years) from BHS were observed. Between July 2008 and June 2015, average Medicare episode expenditures declined 20.8%, from $26 785 to $21 208 (P < .001) for 3738 episodes of joint replacement without complications. It declined 13.8% from $38 537 to $33 216 (P = .61) for 204 episodes of joint replacement with complications. Readmissions and emergency department visits declined 1.4% (P = .14) and 0.9% (P = .98), respectively, while episodes with prolonged length of stay decreased 67.0% (P < .001). Patient illness severity remained stable. By 2015, 51.2% of overall hospital savings had come from internal cost reductions and 48.8% from PAC spending reductions. Reductions in implant costs, down on average $1920.68 (29%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined $2443.12 (27%) per case, largely from reductions in inpatient rehabilitation and skilled nursing facility spending but only when bundles included financial responsibility for PAC.Conclusions and RelevanceDuring a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.

Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative.

In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.

Bundled Payments for Care Improvement: Lessons Learned in the First Year.

The Bundled Payments for Care Improvement (BPCI) initiative is the latest cost-saving program developed by the Center for Medicare and Medicaid Innovation. This model is intended to create a system for higher quality and more coordinated care at a lower cost to Medicare. It is currently an optional program for physician groups, hospitals and post-acute care providers to benefit financially from improved care models and cost containment measures. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. Under this initiative, there are certain fraud and abuse waivers in place that allow gainsharing among BPCI organizations and approved providers so long as certain requirements are met. Our practice entered this initiative for total joint arthroplasty episodes of care as well as the hip and femur fracture episode of care. The first year experience demonstrated that a significant learning curve is required. Keys for success include appropriate patient selection for elective surgery, implant pricing control, adherence to preoperative and postoperative protocols, diligent postcare care management, and appropriate choice of metrics to maximize gainsharing potential. Ultimately, the BPCI program has been a successful venture, saving our hospitals over $1.6 million in 2015. In the process, this provided an additional revenue stream for our physicians while decreasing the overall cost of care.

A Single-Center Cost Analysis of Treating Primary and Metastatic Brain Cancers with Either Brain Laser Interstitial Thermal Therapy (LITT) or Craniotomy.

BackgroundBrain laser interstitial thermal therapy (LITT) under magnetic resonance imaging (MRI) guidance has recently gained US clinical approval for the ablation of soft, neurological tissue. LITT is a minimally invasive alternative to craniotomy.ObjectiveWhile safety and efficacy are the focus of most current LITT studies, it is unclear how acute care costs (inpatient care ± aftercare) of LITT compare to craniotomy in an academic medical center. Therefore, the purpose of this analysis is to examine these costs of using brain LITT under MRI guidance compared to craniotomy in complex anatomies.MethodsConsecutive patients treated at a single US center from 1 January 2010 to 21 October 2014 were retrospectively evaluated. Patients were included if they had a primary procedure for LITT or craniotomy (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] procedure code 17.61 or ICD-9-CM procedure code 01.59, respectively) and were subgrouped according to their diagnosis of primary brain or metastatic brain cancer (ICD-9-CM 191.0–191.9 or ICD-9-CM 198.3, respectively). Patients were excluded if they had co-morbid conditions such as brain edema (ICD-9-CM 348.5). Patients were matched (LITT vs. craniotomy) based on diagnosis. Appropriate statistical analyses were undertaken to examine the year 2015 costs for care in all settings (acute hospital and post-hospital care, i.e., skilled nursing facility, rehabilitation, and home care) were examined.ResultsIn patients treated for a primary brain cancer, there was no statistical difference in the acute and post-care costs of LITT and craniotomy (inverse variance, mean difference [MD], random effects model): MD = −US$1669; 95% confidence interval (CI) −$8192 to $4854; P = 0.62. When examining difficult to access primary malignancies, no difference was found: MD = −US$4719; 95% CI −$12,183 to $2745; P = 0.22. In metastatic brain cancer, LITT was found to be significantly less costly than craniotomy: MD = −US$6522; 95% CI −$11,911 to −$1133; P = 0.02.ConclusionsIn patients with metastatic brain cancer, LITT is less costly than craniotomy. Patients receiving LITT had a significantly shorter length of hospital stay, were significantly older, and were more likely to be discharged home. The use of LITT may be a reasonable option in bundled episodes of care for brain cancer and may fit into the Bundled Payment for Care Improvement (BPCI) program being evaluated by Medicare and providers.

Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy: An Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume. The first pathway, MIPS, consolidates several Medicare quality-reporting programs into one composite score that will be derived by four performance categories, including quality (30%), resource utilization (30%), meaningful use (25%), and clinical practice improvement activities (15%). The APM pathway includes the following programs: Medicare accountable care organizations as part of the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Comprehensive Primary Care initiative. Existing APMs have yet to be determined as eligible. We provide a contextual framework of the healthcare legislation that has led to the formation of current health policy and offer recommendations regarding SGR how orthopaedic surgeons may best steer through such reimbursement models.