Bundled Payments for Care Improvement Initiative: The Next Evolution of Payment Formulations

Froimson, Mark I.; Rana, Adam J.; White, Richard E.; Marshall, Amanda; Schutzer, Steve F.; Healy, William L.; Naas, Peggy; Daubert, Gail; Iorio, Richard; Parsley, Brian S.

doi:10.1016/j.arth.2013.07.012

Cited by 157 publications

(82 citation statements)

References 8 publications

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“…Episode-of-care payment models encourage such efficiency by providing healthcare systems with one lump-sum payment for a group of services required for a circumscribed diagnosis or procedure [9,27]. Elective primary TKA frequently is cited as an archetype of a procedure amenable to bundled payment [13]. However empirical data describing Medicare payments for TKA using an episode-of-care approach are almost nonexistent.…”

Section: Discussionmentioning

confidence: 99%

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Cram

Ravi

Vaughan-Sarrazin

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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Background Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited. Questions/purposes We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained? Methods We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whetherThe institution of one of the authors (PC) has received, during the study period, funding from the National Institutes of Health (K24 AR062133 and R01 AG033035). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that the institutional review board at the University of Iowa approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at the University of Iowa, Iowa City, IA. Clinical Orthopaedics and Related Research ®A Publication of The Association of Bone and Joint Surgeons® differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors. Results There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,323

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Section: Discussionmentioning

confidence: 99%

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

Cram

Ravi

Vaughan-Sarrazin

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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“…To improve outcomes and help decrease the costs of this increased total joint replacement volume, the BPCI program was initiated to hold institutions and providers more accountable for the delivery of care. The BPCI initiative has been shown to improve overall patient care and decrease healthcare costs in some instances [3]. Identifying patients at greater risk for complications and readmission and appropriately educating and managing them preoperatively through an algorithmic approach to maximize their healthcare status is critical to the success of this value-based healthcare model.…”

Section: Discussionmentioning

confidence: 99%

High Risk of Readmission in Octogenarians Undergoing Primary Hip Arthroplasty

Malkani

Dilworth

Ong

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background As life expectancy increases, more elderly patients with end-stage hip arthritis are electing to undergo primary THA. Octogenarians undergoing THA have more comorbidities than younger patients, but this is not reflected in risk adjustment models for bundled care programs. The burden of care associated with THA in octogenarians has not been well characterized, and doing so may help these value-based programs make adjustments so that this vulnerable patient population does not risk losing access under accountable care models.Questions/purposes The purpose of this study was to describe care use, comorbidities, and complications among octogenarians undergoing primary THA. Methods Five percent of the Medicare national administrative claims data was queried to identify patients diagnosed with hip osteoarthritis between January 1, 1998, and December 31, 2013. Patients who underwent primary THA were identified and followed longitudinally during the study period using their unique, encrypted Medicare beneficiary identifiers. We compared risk factors and complications between the octogenarian group versus those aged 65 to 69 years. Multivariate Cox regression was used to evaluate the effect of patient/hospital factors on risk of revision, periprosthetic joint infection, dislocation, venous thromboembolism (VTE), and mortality. Patient factors in the model included age, sex, race, region, socioeconomic status, and health status based on Charlson comorbidity score 12 months before replacement surgery. Results There were 11,960 THAs in the octogenarians in 1998, which increased to 21,620 in 2013, an 81% increase during this study period. Octogenarians were more likely to have a Charlson score of 3 or higher than those patients aged 65 to 69 years (30% versus 17%, odds ratio [OR] 2.07 [1.98-2.20]; p \ 0.001), and they were more likely to have coronary artery disease or congestive heart failure (47% versus 29%, OR 2.16 [2.06-2.26]; p \ 0.001). The octogenarian group had a greater risk of dislocation (+12%, p = 0.01), VTE (+14%, p\0.001), and mortality (+150%, p\ 0.001) compared with the younger age cohort. A total of 21% of the octogenarians were readmitted after surgery compared with 12% for patients in the younger group (OR=1.64, 95% confidence interval 1.54-1.75; p \ 0.001). Conclusions Because octogenarians are at increased risk of dislocation, VTE, medical complications, and mortality after THA, value-based care models that penalize hospitals One or more of the authors (KO, DB, EL) are employees of Exponent, Inc. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. This work was performed at

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“…Though limited to facilities in the Southwestern USA, participating centers reported lower costs with no notable impact on patient outcomes [14,26].…”

Section: The Evolution Of Bundled Payment Modelsmentioning

confidence: 99%

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

McLawhorn

Buller

2017

Curr Rev Musculoskelet Med

131

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Bundled Payments for Care Improvement Initiative: The Next Evolution of Payment Formulations

Cited by 157 publications

References 8 publications

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

What Drives Variation in Episode-of-care Payments for Primary TKA? An Analysis of Medicare Administrative Data

High Risk of Readmission in Octogenarians Undergoing Primary Hip Arthroplasty

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

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