Participation in BPCI for joint replacement surgery linked with decreased episode spending
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Under the Bundled Payments for Care Improvement program, participation in bundled payment for lower extremity joint replacement for 3 years correlated with episode savings compared with nonparticipation, according to study results. However, investigators noted the savings were driven by early participants and did not correlate with changes in quality.
“Bundled payments for hip and knee replacement surgery work,” Amol S. Navathe, MD, told Healio Orthopedics. “Although the savings may be smaller than we had previously thought, this is one of the few Medicare programs that has saved money while doing good for patient care.”
The baseline period in the study f or the pre-Bundled Payment Care Improvement (pre-BPCI) was from January 2011 to September 201 3 and the intervention period f or the entire BPCI was from October 2013 to December 2016. Researchers then divided the intervention period into early BPCI (October 2013 to June 2015) and the late BPCI period (July 2015 to December 2016).
Researchers identified 244 B P CI hospitals in 123 BPCI markets in the BPCI period. There were 10,757 BPCI patients per quarter in the early period and 10,949 BPCI patients in the late BPCI period. Investigators noted the matched comparison group included 244 non-BPCI hospitals i n 98 non-BPCI markets during the BPCI period. At non-BPCI hospitals , t here were 2,819 non-BPCI patients per quarter in the early BPCI period and 2,375 non-BPCI patients in the late BPCI period.
The average Medicare payment per lower extremity joint replacement surgery episode was the primary spending outcome. Other outcomes included the proportion of average episode spending attributable to index hospitalization, readmission, skilled nurse facility care and inpatient rehabilitation facility care, home health agency s ervices and professional services . Investigators compared B P CI hospitals with non-BPCI hospitals and also analyzed patient, hospital and market characteristics.
Results showed that among non-BPCI patients, the mean episode spending was $22,834 in the pre- BPCI period and was $22,073 in the BPCI period . Investigators noted participation in BPCI compared with no participation in BPCI for 3 years correlated with a 1.6% differential decrease in the average lower extremity joint replacement episode spending. Twenty-seven percent of episode savings were due to patient selection.
Navathe said, “This is likely the most proven value-based model that Medicare has tested. While the magnitude of savings is not a 'home run,' extending to other orthopedic surgeons nationwide would be a sensible way to scale the impact.” – by Monica Jaramillo
Disclosure: Navathe reports no relevant financial disclosures.
Perspective
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Jack M. Bert, MD
Since the onset of the bundled payment initiative by Medicare, in those programs that have been successful, it is possible that surgeons enrolled in those programs who had privileges at multiple hospitals, preferentially sent optimized or low-risk patients to BPCI hospitals while doing TJA on higher-risk patients at non-BPCI hospitals. In today’s environment, those surgeons who own their ASCs are careful to perform outpatient TJA in low-risk commercially insured patients to avoid transfer to a hospital to avoid “bundle buster” or “avalanche cases.” With TKA removed from the inpatient only list, this trend may continue in select patients despite the low reimbursement projected to be approximately $8,600 for 2020 (personal communication. Josh Kerr, deputy director of American Association of Hip and Knee Surgeons, 1/9/20).
In the review by Navathe of the first 3 years of Medicare’s BPCI project in 244 BPCI hospitals in 123 BPCI markets during the BPCI period, there were no significant differential changes between BPCI and non-BPCI patients in 90-day risk standardized mortality. Furthermore, there was no association with changes in quality outcomes when evaluated specifically by program period or duration of hospital participation. Of interest is that there was a 1.6 % decrease in TJA spending with no changes in outcomes. Medicare thus is planning to expand voluntary bundles thru BPCI Advanced. However, as implied above, patient selection did account for 27 % of episode savings.
One of the major problems with this article however is that there may be a difference in study samples and variables and thus unobserved selection can still occur. It is clear that patient selection is critical to avoid complications and readmissions in TJR, however, Medicare, like commercial payers, are desirous of employing bundled payments to contain costs which have been shown with appropriate optimization and expansion of patient selection can result in outpatient or short patient stays with minimal complication rates. In the future, as the bundled payment shift continues, providers will be forced to take on more risk and thus managing their patient’s comorbidities will determine the success or failure of a bundled payment episode.
University of Minnesota School of Medicine
Woodbury Bone & Joint Specialists Ltd.
Woodbury, Minnesota
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