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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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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
Now Over 1,000,000 THA and TKA Cases Annually
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Overview
Introduction to Bundled Payment
Comprehensive Care for Joint Replacement
Opportunities for the Acute Pain Service
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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
Introduction to Bundled Payment
Comprehensive Care for Joint Replacement
Opportunities for the Acute Pain Service
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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 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
Introduction to Bundled Payment
Comprehensive Care for Joint Replacement
Opportunities for the Acute Pain Service
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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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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