The Successful Future Of TKA Digging Your Way Through Bundle Syllabus
2015-10-05
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10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT Migration of care in TJA Steven B. Haas MD, MPH Chief, Knee Service John N. Insall Chair, Knee Surgery The Hospital for Special Surgery New York, NY Disclosure • Smith & Nephew Orthopaedics • Designer (Royalty income), Consultant and Research Support on Knee Products • APOS Therapy • Medical Advisory Board • SandDance Technology – Ownership • IMP – Royalty ADULT RECONSTRUCTION AND JOINT REPLACEMENT Migration of care in TJA in 2015 ● ● ● ● Improved knowledge ● Entire care pathway practices Improved technology Patient factors ● Increasing life expectancy ● Expanding indications ● Millennium patient ● No longer primarily geriatric orthopedics ● More demanding patients ALL ROADS LEAD TO RAPID RECOVERY ● Both in ASCs & Hospitals ADULT RECONSTRUCTION AND JOINT REPLACEMENT 1 10/5/2015 Why do we care about rapid recovery? ● Is it for the science? ● Current consensus is that mid-term to long-term results are similar regardless of short-term results ● Available resolution of measurement tools? ADULT RECONSTRUCTION AND JOINT REPLACEMENT Why do we care about rapid recovery? ● “It’s not about how much money you spend, it’s about where you spend the money you have.” - Fred Cushner, MD ● COST CONTAINMENT ● ● ● ● Global endeavor Decrease in healthcare $ Decrease available patient resources If you’re not careful: ● ● ● Can affect patient care Your quality Disempowers surgeon ADULT RECONSTRUCTION AND JOINT REPLACEMENT Why do we care about rapid recovery? ● COST CONTAINMENT = improve efficiencies ● ● ● ● ● ● ● ● Technique Implant cost Pharmacy OR utilization Ancillary services Nursing utilization Discharge status ● Acute Rehab ● Nursing facility ● Home Hospital Length of Stay ADULT RECONSTRUCTION AND JOINT REPLACEMENT 2 10/5/2015 Factors that may matter for recovery Implant Technologies Technique ADULT RECONSTRUCTION AND JOINT REPLACEMENT Technique is important ● But not enough by itself ● MIS approaches ● Most important to do the surgery well ● Blood conservation techniques Alternative anesthesia ● Multimodal pain control ● ADULT RECONSTRUCTION AND JOINT REPLACEMENT Factors that may matter for recovery Implant Technologies Technique ADULT RECONSTRUCTION AND JOINT REPLACEMENT 3 10/5/2015 New Technologies to Improve Efficiency & Outcome •Visionaire – PSI •FastPaK – Disposable Instruments ADULT RECONSTRUCTION AND JOINT REPLACEMENT New Technologies that May Improve Outcome •Orthosensor - Intraop Balancing Sensors •Blue Belt – Robotic Navigated Surgery ADULT RECONSTRUCTION AND JOINT REPLACEMENT Factors that may matter for recovery Implant Technologies Technique ADULT RECONSTRUCTION AND JOINT REPLACEMENT 4 10/5/2015 Technology needs to meet patient expectations and demands • Our Younger Active Patients want to: Skiing ADULT RECONSTRUCTION AND JOINT REPLACEMENT Golfing Racket Sports ADULT RECONSTRUCTION AND JOINT REPLACEMENT Performance/Satisfaction of TKA’s v THA? • Post THA: sports activities increased from 36% to 52% • Post TKA: sports activities decreased from 42% to 34% The Ulm Osteoarthritis Study- K Huch • Up to 20% of patients are not satisfied with the outcome following total knee replacement • Only 82% to 89% of primary TKA patients are satisfied J Bone Joint Surg Br. 2010 Sep;92(9): Scott CE, Howie CR, MacDonald D, Biant LC Clin Orthop Relat Res. 2010 Jan;468(1):57-63: Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD ADULT RECONSTRUCTION AND JOINT REPLACEMENT 5 10/5/2015 “Understanding Normal Knee Kinematics Better – A Dynamic MRI Study” A. Williams M.D. JBJS 2002 MEDIAL ADULT RECONSTRUCTION AND JOINT REPLACEMENT “Understanding Normal Knee Kinematics Better – A Dynamic MRI Study” A. Williams M.D. JBJS 2002 LATERAL ADULT RECONSTRUCTION AND JOINT REPLACEMENT Kinematics – Normal Knee • 0° (Full Extension) – Screw-home (5° femoral internal axial rotation) – Posterior femoral condyle nearly flush with posterior tibia • 0-90° – Medial pivot (rollback + femoral external axial rotation) – Q-angle minimized (quad mechanism in straight line) • 90-155° – Posterior femoral translation – Axial rotation ceases ADULT RECONSTRUCTION AND JOINT REPLACEMENT 6 10/5/2015 Kinematics – Normal Knee ADULT RECONSTRUCTION AND JOINT REPLACEMENT Traditional TKA limitations Non-anatomic (abnormal) positioning • Paradoxical motion (anterior sliding) 8-13 mm ADULT RECONSTRUCTION AND JOINT REPLACEMENT Conventional TKA limitations Non-anatomic (abnormal) motion • Paradoxical motion (anterior sliding) • No Rotation or even Lateral pivoting Conventional Knee ADULT RECONSTRUCTION AND JOINT REPLACEMENT 7 10/5/2015 Abnormal kinematic patterns • Forward sliding of the femur – Posterior impingement – Extensor mechanism lever arm • Victor J, Banks S, Bellemans J: Kinematics of posterior cruciate ligament retaining and substituting total knee replacements. J Bone Joint Surg Br. 2005 May; 87 (5) ADULT RECONSTRUCTION AND JOINT REPLACEMENT Abnormal kinematic patterns • Forward sliding of the femur – Posterior impingement – Extensor mechanism lever arm • Axial rotation – Limited or Reverse femoral/tibial rotation ~ Q-angle Victor J, Banks S, Bellemans J: Kinematics of posterior cruciate ligament retaining and substituting total knee replacements. J Bone Joint Surg Br. 2005 May; 87 (5) ADULT RECONSTRUCTION AND JOINT REPLACEMENT Patellar ML Shear Force 250 Force (N) Reverse tibial rotation – lateral pivot 200 150 100 50 0 -50 0 30 60 90 120 150 Flexion Angle (deg) LATERAL Q MEDIAL ADULT RECONSTRUCTION AND JOINT REPLACEMENT 8 10/5/2015 Correct tibial rotation LATERAL MEDIAL Q ADULT RECONSTRUCTION AND JOINT REPLACEMENT Solutions? • Either retain both cruciates • Either substitute for both cruciates ADULT RECONSTRUCTION AND JOINT REPLACEMENT Saving Both Cruciates • Limited number of ideal patients • Technically difficult for most surgeons • Potential new complications (ACL avulsion / fx) • Anatomic shapes likely more desired ADULT RECONSTRUCTION AND JOINT REPLACEMENT 9 10/5/2015 HYPOTHESIS •As TKA is a surface replacement within an existing soft tissue envelope, we assume that the lack of restoration of normal anatomic contours and kinematic patterns is the reason for impaired function ADULT RECONSTRUCTION AND JOINT REPLACEMENT Normal anatomic contours • CT and MRI antropomorphic data • Computer modeling and simulation • Femoral/Tibial geometry controlled with over 80 parameters lateral medial ADULT RECONSTRUCTION AND JOINT REPLACEMENT Normal anatomic contour matching • Reproduces Normal Kinematics Flexion and Stability – Precise Matching of Normal Anatomy • Most Anatomically Correct for Females & Males – Differing Tibial Geometry Medial / Lateral ADULT RECONSTRUCTION AND JOINT REPLACEMENT 10 10/5/2015 Anatomic contours matching ADULT RECONSTRUCTION AND JOINT REPLACEMENT Anatomic contours matching - tibia High ML Conformity ADULT RECONSTRUCTION AND JOINT REPLACEMENT Anatomic contours matching - tibia medial lateral ADULT RECONSTRUCTION AND JOINT REPLACEMENT 11 10/5/2015 Anatomic contours matching • Cupped medial compartment • Sloped lateral compartment ADULT RECONSTRUCTION AND JOINT REPLACEMENT Normal Anatomy, TKA and Joint Line lateral joint line level medial joint line level OUCH Normal Anatomy, TKA and Joint Line 12 10/5/2015 Anatomic contours matching Bone resection Bone resection –If you want kinematic alignment, why not do it the right way? • Avoid internal rotation of femur • Avoid excessive valgus/varus tibia resections ADULT RECONSTRUCTION AND JOINT REPLACEMENT Anterior Cam –Provides anterior stabilization during early gait (up to 20° flexion) –Maximized contact area ADULT RECONSTRUCTION AND JOINT REPLACEMENT Designed Roll Back – Traditional PS knee ADULT RECONSTRUCTION AND JOINT REPLACEMENT 13 10/5/2015 Asymmetric Posterior Cam ADULT RECONSTRUCTION AND JOINT REPLACEMENT Bicruciate Substituting & Retaining AP Position and Rotation ADULT RECONSTRUCTION AND JOINT REPLACEMENT Results - KINEMATICS A/P medial CP [%TibSize] 80 60 40 20 0 10 20 30 40 50 60 70 80 90 Flexion [Deg] <--Pos A/P location [%TibSize] Ant--> <--Pos A/P location [%TibSize] Ant--> • The average axial tibiofemoral rotation from full extension to maximum flexion for all TKAs was 10.8° • • 95% normal axial rotation patterns 100% posterior femoral translation • “BCS designs were able to achieve early femoral rollback and external femoral rotation, both hallmarks of healthy intact knee motion” A/P lateral CP [%TibSize] 80 60 40 20 0 10 20 30 40 50 60 70 80 90 Flexion [Deg] ADULT RECONSTRUCTION AND JOINT REPLACEMENT 14 10/5/2015 Implant Conclusion • While successful, TKR patients are frequently limited in higher level activity • Traditional TKR do NOT reproduce normal kinematics • JOURNEY II BCS is designed to allow for more normal kinematics • Improvements in kinematics may lead to improved performance of higher level activity ADULT RECONSTRUCTION AND JOINT REPLACEMENT Overall summary ● Business of medicine affects your quality of care ● Rapid recovery model for TJA ● Little to do with “kicking patients out” ● More to do with adopting best clinical practices ● It’s a clinical, scientific & financial shift ● ● TJA landscape is changing Multiple variables affect recovery speed ● We all are learning from each other’s experiences ● NEW TECHNOLOGY CAN IMPROVE BOTH ● Efficiency ● Quality ADULT RECONSTRUCTION AND JOINT REPLACEMENT 15 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT Clinical Results & OR Efficiencies David J. Mayman, MD Associate Professor The Hospital for Special Surgery New York, NY Disclosures Consultant: Mako/Stryker Consultant: Smith and Nephew OrthAlign Stock Options ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY II TKA: Excelling in The Bundle • Single Site Registry – Early reports • 2 Single-Site: Early outcome reports – Dr. Bill Huang – Dr. Dave Mayman ADULT RECONSTRUCTION AND JOINT REPLACEMENT 16 10/5/2015 JOURNEY™ II BCS: Patient Satisfaction Dr. Mark Snyder Registry Experience Mark A Snyder, MD Director, Orthopaedic Center of Excellence Good Samaritan Hospital Med Exec, Trihealth Orthopaedic & Spine Institute Cincinnati, Ohio • Redcap Registry Database, level-3 data • JOURNEY II BCS outcomes data at 1 year • n = 56 • Mean age = 59 ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: Patient Satisfaction Dr. Mark Snyder Registry Experience • Pre-op EuroQol5: 50 (35 to 70) • Post-op EuroQol5: 93 (60 to 100) • Statistically insignificantly different from THA in young patients! • Mean flexion 130.7o (115o to 145o) • Patient satisfaction (VAS 1-10 Scale) 9.4 (98.7 %) • Risk Adjusted 30-day Readmission Rate: 0% • Relevant Surgical Complication Rate: 0% (National range 4-6%) ADULT RECONSTRUCTION AND JOINT REPLACEMENT • No transfusions and no venous thromboembolisms JOURNEY™ II BCS: Patient Satisfaction Dr. Mark Snyder Registry Experience • Pre-op UCLA activity score: 4.7 (3 to 6) • Post-op UCLA activity score: 7.3 (6 to 9) • Competes with THA and RHA improvements in patients! – Groin pain after metal on metal hip resurfacing: a mid-term follow-up of a prospective cohort of patients. Illical E, et a. HSS J 2012;8(3):257 – Physical activity before and after primary total hip arthroplasty: A registry-based study. Lubbeke A, et al. Arthritis Care Res 2013 Aug 7 [Epub] • At 1 year 88% in sports and 100% back to work! ADULT RECONSTRUCTION AND JOINT REPLACEMENT 17 10/5/2015 JOURNEY II TKA: Excelling in The Bundle • Single Site Registry – Early reports • 2 Single-Site: Early outcome reports – Dr. Bill Huang – Dr. Dave Mayman ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: LOS Reduction Bill Huang , MD • • • • • Fellowship-trained arthroplasty surgeon Practices exclusively in hip and knee replacements Private practice in a community hospital Averages 250 TKR/UNI and 200 THA per year 50 revisions per year • • • • Almost exclusively PS TKR user 2007-2009 – Legion, Journey 1 BCS, & PFC Sigma RP 2009 - 2013 – Legion 2013 - 2015 – Legion & Journey 2 BCS ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: LOS Reduction Bill Huang MD -- early outcome Legion PS Primary PS Methods: • Functional scores • Radiographic follow-up – Knee Society Score • • • • n: 50 Mean age: 61.9 Average BMI: 34 M/F ratio: 54%/46% – Pre op – 1 months – 4 months • • Complications Technical Data Journey 2 BCS • • • • n: 50 Mean age: 60.4 Average BMI: 36.1 M/F ratio: 51%/49% ADULT RECONSTRUCTION AND JOINT REPLACEMENT 18 10/5/2015 JOURNEY™ II BCS: LOS Reduction Bill Huang MD JOURNEY II BCS LEGION Primary PS • • Tourniquet time: 42 minutes LOS: 2.4 days • • Tourniquet time: 45 minutes LOS: 1.8 days • • • Pre Op: 6.5 – 108 1 month: 3.7 – 108 4 months: 0.58 – 127.4 • • • • • Wound issues: 1 Infection: 0 VTE: 0 Reoperation: 0 MUA: 1 ROM • • • Pre Op: 6.8 – 110.1 1 month: 3.2 – 90.1 4 months: 0.66 – 122.4 Complications • • • • • Wound issues: 2 Infection: 0 VTE: 0 Reoperation: 0 MUA: 3 ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: LOS Reduction Bill Huang MD -- Knee Society Scores Legion PS Primary PS KNEE SCORE • Pre Op: 42.8 • 1 month: 64 • 4 months: 87.6 FUNCTION SCORE • Pre Op: 59 • 1 month: 76 • 4 months: 98 Journey 2 BCS KNEE SCORE • Pre Op: 43.2 • 1 month: 69.6 • 4 months: 92.6 FUNCTION SCORE • Pre Op: 62 • 1 month: 79 • 4 months: 98 ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: LOS Reduction Bill Huang, MD Early Outcome Experience Key Points: • JOURNEY II BCS Achieved: – Earlier, Greater ROM – Higher KS Scores – Less MUA rate • Anecdotal Patient Comments: – Less pain and less narcotic usage in first 4 months – Less joint swelling/effusion in first 1 months – Easier getting up from seated position – Feels less “mechanical” ADULT RECONSTRUCTION AND JOINT REPLACEMENT 19 10/5/2015 JOURNEY II TKA: Excelling in The Bundle • Single Site Registry – Early reports • 2 Single-Site: Early outcome reports – Dr. Bill Huang – Dr. Dave Mayman ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: Functional Improvement David Mayman, MD Early Outcome Experience Methods: • N= 200 retrospectively reviewed • 100 TKA with Legion • 100 TKA with Journey • 113 females and 87 males • Mean age 51 years ( range 43-66) • All patients underwent a clinical exam and post-operative ROM was recorded at 6 weeks ADULT RECONSTRUCTION AND JOINT REPLACEMENT JOURNEY™ II BCS: Functional Improvement David Mayman, MD Results: • • Average ROM • Legion 96° (range 85-116) • Journey 119°(range 95-125) Average Pain (KSS) • • Legion: 30 Journey: 37 Conclusion: • There was a significant and clinically relevant improvement in flexion in patients who underwent a TKA with a JOURNEY II TKA implant (p<.0001) • Patients who undergo a TKR with a Journey implant have better range of motion and less pain post-operatively at 6 weeks. • This study suggests that an implant design that more closely replicates the normal anatomic joint line and knee kinematic patterns may help reduce some of the dissatisfaction following TKA. ADULT RECONSTRUCTION AND JOINT REPLACEMENT 20 10/5/2015 Efficiency Has Not Been Addressed • Why do we have trial implants in the room for right and left knees? • Why do we have trials for every size implant in the room? • Relies on sterilizing many trays ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT 21 10/5/2015 What can we do to improve this? Smith and Nephew has come up with three options to address as many surgeons and hospitals as possible • Option 1 – Template Derived Instrumentation • Option 2 – VISIONAIRE™ • Option 3 – Disposable instruments with VISIONAIRE™ ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT Pre-Operative Templating Digital Templating • Anticipate sizes of components • Avoid leg length discrepancy • Restore offset • Avoid femoral fracture • Avoid instability ADULT RECONSTRUCTION AND JOINT REPLACEMENT 22 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT Accuracy of Digital Templating for TKA • N=71 patients (76 knees) • Standing anteroposterior and lateral knee digital radiographs • Calibrated using a 25mm calibration marker • Templated sizes for the femoral and tibial components compared to implanted sizes. ADULT RECONSTRUCTION AND JOINT REPLACEMENT 23 10/5/2015 Results Tibia and Femur were both exact = 43/76 (63%) Tibia and Femur ± 1 size = 74/76 ( 97%) ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT Template Derived Instrumentation ™ ™ ADULT RECONSTRUCTION AND JOINT REPLACEMENT 24 10/5/2015 Instruments Picked From Plan ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT 25 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT 26 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT 27 10/5/2015 Visionaire • Takes the pre-operative templating and advances the accuracy • Has the potential to improve efficiency further • MRI and long leg x-rays required • Must be done at least 3 weeks prior to surgery • Surgeon receives a plan from an engineer that is approved by the surgeon and then patient specific cutting guides are created ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT 28 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT Disposables • Disposable instruments build on the experience of VISIONAIRE™ and takes efficiency in the OR to the next step ADULT RECONSTRUCTION AND JOINT REPLACEMENT Poly Trials Tibial Trial Femoral Trial Femoral cutting Block Tibial cut block Distal femoral Cutting block ADULT RECONSTRUCTION AND JOINT REPLACEMENT 29 10/5/2015 ADULT RECONSTRUCTION AND JOINT REPLACEMENT ADULT RECONSTRUCTION AND JOINT REPLACEMENT Summary • Pre-operative templating is an accurate method for predetermining implants w/I 1 size • Patient specific instrumentation of some sort can help improve the efficiency of delivery • As demand increases and reimbursement decreases we need to improve efficiency while maintaining or improving quality. ADULT RECONSTRUCTION AND JOINT REPLACEMENT 30 10/5/2015 Thank you ADULT RECONSTRUCTION AND JOINT REPLACEMENT 31 10/5/2015 Digging Your Way Through the Bundle New Developments in CMS Policy 2015 and Beyond Peter C. Geagan –Director of Commercialization, Smith & Nephew, Inc. 1 Inspired Leadership Facilitates Change Do you know the true costs of your episode of care? • “When TDABC is fully embraced we will know the true cost of an episode of care” – Michael Porter, Bishop William Lawrence University Professor at The Institute for Strategy and Competitiveness, Harvard Business School 1 • “If you cannot measure your outcomes & quality, then someone will report what they measure and report it” - Dr. Joseph Iannotti, Professor and Chair Orthopaedic and Rheumatologic Institute, Clinical Transformation, Cleveland Clinic 1 Culture Change Is Key 2 1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DC Agenda What Bundled Payment Programs When Why 3 1 10/5/2015 History of Bundled Payments 1980 2000 2010 2010 2012 2013 2015 4 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-30-2.html Impact of the Affordable Care Act (2010) Payment reform accelerating is accelerating accelerating the pace of change Shifting from volume based payments to value based payments BPCI CCJR HRRP HAC VBP ACOs MSSP More emphasis on quality metrics & outcomes & less on RVUs 5 Moving toward shared risk contracts and capitation models Why the Shift to Bundles in TJA? • 2014 over 475,000 inpatient primary TJA were paid for through CMS • TJA accounts for over $15 Billion in annual CMS spend • Tremendous variance in cost and quality of care for TJA in the 90 day episode • $16,500 to $33,000 across geographic areas • Post Acute Care utilization & quality varied by site of service • Rate of infections and implant failures varied greatly -3x in some cases requiring readmission to hospital 6 http://innovation.cms.gov/initiatives/ccjr/ 2 10/5/2015 Why Shift? – Variation within the bundle Key Findings Hip Replacements Wide cost variances currently exist across a TJA episode of care $30,000 $25,000 $20,000 $15,000 With the most variation occurring during the post-acute aspect of the bundle $10,000 $5,000 $Lowest Cost Highest Cost Index Hospitalization Variation Physician Services Readmissions Post Discharge Care 7 Miller, D.C., et al (2011). Large Variations in Medicare Payments for Surgery Highlight Savings Potential From Bundled Payment Programs. Health Affairs, 30 (11). 2107-2115. Bundled Payment - Overview Fee-For-Service Vs. Bundled Payment Payment for comprehensive, coordinated intervention Payment for each service regardless of quantity or quality $ $ Pre-Admission Services $ $ Part A Inpatient Services (Hospital) $ $ $ Part B Inpatient Services (MDs) Readmissions Post-Acute Costs (Part A & Part B) 8 http://innovation.cms.gov/initiatives/bundled-payments Medicare Payment Method Shift Target percentage of Medicare Fee for Service payments linked to quality and bundled payment models 2016 2018 All Medicare FFS All Medicare FFS 90% - Payments linked to quality 85% - Payments linked to quality 50% - Bundled Payments 30% Bundled Payments Change 10 Center for Medicare and Medicaid Innovation, 8/1/ 2013 (CMS.gov) 3 10/5/2015 Alternative Payment Models MSSP BPCI CCJR National Reach 75 MSA’s Gain Sharing Timeline Participation Agreement Annual 3-Pre 90-Post Admission 90-Post Various Models Mandatory 11 http://innovation.cms.gov/initiatives/bundled-payments/ http://innovation.cms.gov/initiatives/ccjr/ https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-30-2.html BPCI: Brief overview Covers 48 different episodes of care (DRGs) • 78% participants chose lower extremity joint replacement Bundled Payment for Care Improvement • • 4 different voluntary models (Models 1, 2, 3, and 4) Controlled by (any) ‐ ‐ ‐ • Physician group (295) Hospital (403) 3rd Party Convener Outcome Measures ‐ Implementation Plan (IP) proposed by awardee outlines quality metrics to be improved ‐ Goal of aligning inpatient and post-acute care pathways to increase quality and reduce costs • Bundle Price Target (2-3% off 3 yr avg of account’s history): ‐ If costs less than historical spend, savings may be retained/shared owed to ‐ If costs are more than historical spend, payment Admission CMS Discharge ‐ Physician Gain Sharing up to 50% of FFS Episode of Care Horizon 30, 60, 90 days 12 All Medicare Part A / B fee-for-service payments http://innovation.cms.gov/initiatives/bundled-payments/ CMMI BPCI Models (Participants as of July 1,2015) Pre-Admission Services (3 days*) Part A Inpatient Services (Hospital) Part B Inpatient Services (MDs) Post-Acute Costs (Part A & Part B) Related Readmissions (Part A / B) & Unrelated Readmissions (Part B only) Model 1 (11) (retrospective) Model 2 (741) (retrospective) Model 3 (1,353) (retrospective) Model 4 (10) (prospective) Model 2 presents the broadest opportunity to improve care by focusing on the entire continuum of care for targeted DRGs 13 http://innovation.cms.gov/initiatives/bundled-payments 4 10/5/2015 BPCI Update Model 2–August 2015 BPCI Participant motivation: 1. Wanting to learn about payment reform 2. Pursuing the financial opportunities of BPCI 3. Urging of leadership and wanting to be innovative 4. BPCI opportunities to improve quality 5. Alignment with participation in other initiatives. Early results Q4,2013: note –small sample size Inpatient and PAC alignment with 23 of 24 Model 2 awardees Decrease in anchor LOS from 4.6 days to 4.3 days 90 Day Episode of care costs dropped from $37,275 to $32,369 – statistically significant 30 Day Unplanned Readmissions from 8.6% to 6.7% Emergency Dept (no hospital admit) visits from 6.9% to 8.7% No change in Mortality rates • • • • • • 14 The Lewin Group, CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation & Monitoring Annual Report, Feb 2015 Tipping point –Law of Diffusion of Innovation • “It’s about making changes that matter clinically…if we get away from patient care & it’s all about finances, we lose.” -Dr. Jim Weinstein, CEO of Dartmouth/Hitchcock 1 • “No one wants the low-cost/low-quality option” -Dr. Daniel Murrey, CEO of Orthocarolina 1 • “If you cannot prove your outcomes and quality of care is better, then you will compete only on price” -Dr. Joseph Iannotti, Professor and Chair Orthopaedic and Rheumatologic Institute, Clinical Transformation, Cleveland Clinic 1 • “How do you inspire change? Strong physician clinical process leadership integrated with administrative support“ -Dr. Mark Snyder, Medical Executive Tri-Health Orthopedics and Spine Institute 1 • “Make data denial impossible…& keep riveting people on the why (outcomes/efficiency improvement) to overcome the aversion to change.” -Michael Porter, Bishop William Lawrence University Professor at2 The Institute for Strategy and Competitiveness, Harvard Business School 1 15 1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DC 2 “Crossing the Chasm” Geoffrey A. Moore, HarperBusiness, 1991. CCJR: Brief overview Lower Extremity Joint Specific • With and without complications (DRG 469 470) Mandatory Bundled Pay Program by CMS • • • Hospital Controlled Fee - Weighted (shifting to Regional) 4 Outcome Measures ‐ ‐ ‐ ‐ • • • Readmissions Complications Patient Experience (HCAHPS) Additional Financial Incentive for Functional PROs 75 MSA Covered Areas 20% Cap on bonus for savings to hospital 50% Cap on physician FFS Episode Horizon Admission Discharge 90 days 16 All Medicare Part A / B fee-for-service payments 5 10/5/2015 Quality Programs – Above and Beyond BPCI/CCJR HRRP HAC VBP Hospital Readmit Reduction Program Hospital Acquired Condition Value Based Purchasing 3% 1% 1.75% Annual Annual Annual Penalty Only % at Risk Bonuses Improve Quality/Safety Timeline 30 Day Readmits Mandatory https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html 17 Affordable Care Act Penalty Avoidance 2016 -Up to 6.75 % of total Medicare FFS Inpatient revenues hospital wide potentially at risk 18 8/1/15 - Press Ganey Associates Knowledge Brief Hospital Pay for Performance 2015 Update Quality Programs - Affordable Care Act $428 Million in Penalties experienced by Hospitals in 2015 (eroding FFS Medicare Inpatient Revenue) Re-Admissions (HRRP) – up to 3% penalties for highest rates 2,610 were penalized in 2015 (433 more than 2014) • ‐ Potentially Avoidable Readmissions result in approx. $17B Medicare spend ‐ 2015 - $13.3 million was largest penalty for Single Hosp - Avg was -.63%1 Hip/Knee Replacements added as a measure in 2015 based on July 2010-June30 2013 data collection • The three main causes of 30 day readmissions (for TJA) were2 ‐ ‐ ‐ ‐ Wound complications Surgical site infections (SSIs) – Most Costly Medical issues 19 1The Bottom Line of Hospital Readmissions, The Camden Group Insights Blog, Matthew Smith, Setember 18,2015. 2Cost Burden of 30-Day Readmissions Following Medicare Total Hip and Knee Arthroplasty, Joseph A. Bosco III, et al. The Journal of Arthroplasty 2013. 6 10/5/2015 Quality Programs - Affordable Care Act HACs – Hospital Acquired Conditions – ¾ of hospitals with lowest HAC rates held harmless, bottom ¼ get 1% penalty • Domain 1:Pressure ulcer rate (PSI 3); Iatrogenic pneumothorax rate (PSI 6); Central venous catheter-related blood stream infection rate (PSI 7); Postoperative hip fracture rate (PSI 8); Postoperative pulmonary embolism (PE) or deep vein thrombosis rate (DVT) (PSI 12); Postoperative sepsis rate (PSI 13); Wound dehiscence rate (PSI 14); and Accidental puncture and laceration rate (PSI 15). • Domain 2: Central Line-Associated Blood Stream Infection and Catheter-Associated Urinary Tract Infection. VBP –Value Based Purchasing – 1.5% withheld for FY 2015; 1.75% for 2016 • 2016 Score Weighted as follows: Process of Care (SCIPs) (10%), Experience of Care (HCAHPS) (25%), Clinical Outcomes (AMI-HF-PN Mortality-CAUTICLABSI-SSI)(40%), Medicare spending per beneficiary-Efficiency (25%) 20 http://innovation.cms.gov/ Quality Metrics CMMI released a list of quality metrics for monitoring • Measures pull largely from existing reporting programs and fall into: – Case Mix – Utilization and Efficiency – Clinical Quality: Process – Clinical Quality: Outcome – Care Experience • Measures are for hospitals, home health, SNF, IRF, and LTCH • CMMI has not released information on evaluation and performance benchmarks • 6 provider-submitted measures 21 Provider/Physician Response • BPCI/CCJR/HRRP/VBP/HACs Creates visibility to Quality of care such as Complications/Readmissions/excessive Use of Post acute Resources (Bending the Cost Curve) • How will the Episode of Care Redesign process increase functional and quality of life and pain scores? (ICHOM) * • Embrace Culture Change driving Episode of Care Redesign • TDABC (Bozic/Porter), outcomes improvement data, and be willing to employ BPs from early adopters like HSS, CJRI, Geisinger, NOSA * “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DC The International Consortium for Health Outcomes Measurement (ICHOM), Slide 215. 22 7 10/5/2015 One more look at TJA cost drivers… • Implant and Device Acquisition • Hospital Fees • LOS • Physician Fees Admission • Post-Acute Care and Rehabilitation • Readmission Costs • Facility Costs (SNF, Home Health) Discharge 90 Day 10 Year 90 days All Medicare Part A / B fee-for-service payments ‘Prehab’ Phase Acquisition Cost / Hospital Efficiencies Rehabilitatio n and Recovery Long Term Follow Up Medicare FFS Part A and B Breakdown of Cost Across Care Continuum THA (2011-2013). 23 Know Your Why 1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DCJim Weinstein, MD –CEO of DartmouthHitchcock Simon Senick , https://www.youtube.com/watch?v=sioZd3AxmnE 24 Thank you! 25 8
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