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

ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Implant

Technologies Technique

Factors that may matter for recovery

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

Implant

Technique

Factors that may matter for recovery

Technologies

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

TechniqueTechnologies

Factors that may matter for recovery

Implant

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Technology needs to

meet patient expectations

and demands

•Our Younger Active Patients

want to:

Skiing 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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

“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

•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

Kinematics –Normal Knee

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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 Joi nt

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 Joi nt

Surg Br. 2005 May; 87 (5)

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Reverse tibial rotation

–lateral pivot

LATERAL MEDIAL

Patellar ML Shear Force

-50

100

150

200

250

030 60 90 120 150

Flexion Angle (deg)

Force (N)

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Correct tibial rotation

LATERAL MEDIAL

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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

•Reproduces Normal Kinematics Flexion and Stability

–Precise Matching of Normal Anatomy

•Most Anatomically Correct for Females & Males

–Differing Tibial Geometry Medial / Lateral

Normal anatomic contour matching

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Anatomic contours matching

•Cupped medial

compartment

•Sloped lateral

compartment

medial joint line level

lateral joint line level

OUCH

Normal Anatomy, TKA and Joint Line

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Bone resection

Anatomic contours matching

–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

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Asymmetric Posterior Cam

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Bicruciate Substituting & Retaining

AP Position and Rotation

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Results - KINEMATICS

• “BCS designs were able to

achieve early femoral rollback

and external femoral rotation,

both hallmarks of healthy intact

knee motion”

•95% normal axial rotation patterns

•100% posterior femoral translation

•The average axial tibiofemoral

rotation from full extension to

maximum flexion for all TKAs was

10.8°

010 20 30 40 50 60 70 80 90

A/P medial CP [%TibSize]

<--Pos A/P location [%TibSize] Ant-->

Flexion [Deg]

010 20 30 40 50 60 70 80 90

A/P lateral CP [%TibSize]

<--Pos A/P location [%TibSize] Ant-->

Flexion [Deg]

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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

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

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

Disclosures

Consultant: Mako/Stryker

Consultant: Smith and Nephew

OrthAlign Stock Options

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

•Single Site Registry –Early reports

•2 Single-Site: Early outcome reports

–Dr. Bill Huang

–Dr. Dave Mayman

JOURNEY II TKA: Excelling in The Bundle

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

JOURNEY™ II BCS: Patient Satisfaction

Dr. Mark Snyder

Registry Experience

•Redcap Registry Database, level-3 data

•JOURNEY II BCS outcomes data at 1 year

•n = 56

•Mean age = 59

Mark A Snyder, MD

Director, Orthopaedic Center of Excellence

Good Samaritan Hospital

Med Exec, Trihealth Orthopaedic & Spine Institute

Cincinnati, Ohio

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(115oto 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%)

•No transfusions and no venous thromboembolisms

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

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!

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

•Single Site Registry –Early reports

•2 Single-Site: Early outcome reports

–Dr. Bill Huang

–Dr. Dave Mayman

JOURNEY II TKA: Excelling in The Bundle

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

JOURNEY™ II BCS: LOS Reduction

Bill Huang , MD

•Almost exclusively PS TKR user

•2007-2009 –Legion, Journey 1 BCS, & PFC Sigma RP

•2009 -2013 –Legion

•2013 -2015 –Legion & Journey 2 BCS

•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

ADULT RECONSTRUCTION AND JOINT REPLACEMENT

JOURNEY™ II BCS: LOS Reduction

Bill Huang MD -- early outcome

Methods:

•Functional scores

–Knee Society Score

•Radiographic follow-up

–Pre op

–1 months

–4 months

•Complications

•Technical Data

Legion PS Primary PS

•n: 50

•Mean age: 61.9

•Average BMI: 34

•M/F ratio: 54%/46%

Journey 2 BCS

•n: 50

•Mean age: 60.4

•Average BMI: 36.1

•M/F ratio: 51%/49%

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

JOURNEY™ II BCS: LOS Reduction

Bill Huang MD

LEGION Primary PS

•Tourniquet time: 42 minutes

•LOS: 2.4 days

JOURNEY II BCS

•Tourniquet time: 45 minutes

•LOS: 1.8 days

ROM

•Pre Op: 6.8 –110.1

•1 month: 3.2 –90.1

•4 months: 0.66 –122.4

•Pre Op: 6.5 –108

•1 month: 3.7 –108

•4 months: 0.58 –127.4

•Wound issues: 2

•Infection: 0

•VTE: 0

•Reoperation: 0

•MUA: 3

•Wound issues: 1

•Infection: 0

•VTE: 0

•Reoperation: 0

•MUA: 1

Complications

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

Journey 2 BCS

KNEE SCORE

•Pre Op: 43.2

•1 month: 69.6

•4 months: 92.6

FUNCTION SCORE

•Pre Op: 59

•1 month: 76

•4 months: 98

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”

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ADULT RECONSTRUCTION AND JOINT REPLACEMENT

•Single Site Registry –Early reports

•2 Single-Site: Early outcome reports

–Dr. Bill Huang

–Dr. Dave Mayman

JOURNEY II TKA: Excelling in The Bundle

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.

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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 REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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 REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Pre-Operative Templating

ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Digital Templating

•Anticipate sizes of components

•Avoid leg length discrepancy

•Restore offset

•Avoid femoral fracture

•Avoid instability

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT 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.

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Results

Tibia and Femur were both exact = 43/76 (63%)

Tibia and Femur ±1 size = 74/76 ( 97%)

ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Template Derived Instrumentation

ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

™

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Instruments Picked From Plan

ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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 REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT 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 REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Poly

Trials

Tibial Trial

Femoral Trial

Femoral cutting

Block

Tibial cut

block

Distal femoral

Cutting block

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT 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.

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ADULT RECONSTRUCTION AND JOINT REPLACEMENTADULT RECONSTRUCTION AND JOINT REPLACEMENT

Thank you

10/5/2015

New Developments in CMS Policy 2015 and Beyond

Digging Your Way Through the Bundle

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

1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DC

Culture Change Is Key

Agenda

Bundled

Payment

Programs

What

WhyWhen

10/5/2015

2015

History of Bundled Payments

2013

2012

2010

2000

1980

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-30-2.html

acceleratingaccelerating

Impact of the Affordable Care Act (2010)

Payment reform is the pace of change

Shifting from volume based payments to value based

payments

More emphasis on quality metrics & outcomes & less on RVUs

Moving toward shared risk contracts and capitation models 5

BPCI CCJR HRRP HAC VBP ACOs MSSP

accelerating

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

http://innovation.cms.gov/initiatives/ccjr/

10/5/2015

Wide cost variances

currently exist across a

TJA episode of care

With the most variation

occurring during the

post-acute aspect of

the bundle

$30,000

$25,000

$20,000

$15,000

$10,000

$5,000

Lowest Cost Highest Cost Variation

Hip Replacements

Key Findings

Why Shift? –Variation within the bundle

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.

Index Hospitalization

Physician Services

Readmissions

Post Discharge Care

$$$

Fee-For-Service Bundled Payment

Payment for each service regardless of quantity or quality Payment for comprehensive, coordinated intervention

Vs.

Bundled Payment - Overview

Pre-Admission

Services

Part A Inpatient

Services (Hospital)

Part B Inpatient

Services (MDs)

Post-Acute Costs

(Part A & Part B)

Readmissions

http://innovation.cms.gov/initiatives/bundled-payments

Target percentage of Medicare Fee for Service payments linked to quality

and bundled payment models

All Medicare FFS

85% - Payments

linked to quality

30% -

Bundled

Payments

All Medicare FFS

90% - Payments

linked to quality

50% - Bundled

Payments

2016 2018

Change

Medicare Payment Method Shift

Center for Medicare and Medicaid Innovation, 8/1/ 2013 (CMS.gov)

10/5/2015

MSSP BPCI CCJR

National

Reach

Gain

Sharing

Timeline Annual 3-Pre

90-Post

Admission

90-Post

Various

Models

Mandatory

Alternative Payment Models

75 MSA’s

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

Participation

Agreement

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

‐If costs are more than historical spend, payment owed to

CMS

‐Physician Gain Sharing up to 50% of FFS

Episode of Care Horizon

All Medicare Part A / B fee-for-service payments

Admission Discharge

30, 60, 90 days

http://innovation.cms.gov/initiatives/bundled-payments/

(Participants as of

July 1,2015)

Model 1 (11)

(retrospective)

Model 2 (741)

(retrospective)

Model 3 (1,353)

(retrospective)

Model 4 (10)

(prospective)

CMMI BPCI Models

Pre-Admission

Services

(3 days*)

Part A Inpatient

Services

(Hospital)

Part B Inpatient

Services (MDs)

Related Readmissions

(Part A / B) & Unrelated

Readmissions (Part B only)

Post-Acute Costs

(Part A & Part B)

Model 2 presents the broadest opportunity to improve care by focusing on the entire continuum

of care for targeted DRGs

http://innovation.cms.gov/initiatives/bundled-payments

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

The Lewin Group, CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4: Year 1 Evaluation & Monitoring Annual Report, Feb 2015

• “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

• “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 at The Institute for Strategy and

Competitiveness, Harvard Business School 1

1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DC

2 “Crossing the Chasm” Geoffrey A. Moore, HarperBusiness, 1991.

Tipping point –Law of Diffusion of Innovation

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

All Medicare Part A / B fee-for-service payments

Admission Discharge

90 days

10/5/2015

HRRP

Hospital Readmit

Reduction Program

HAC

Hospital Acquired

Condition

VBP

Value Based

Purchasing

Penalty

Only

Improve

Quality/Safety

Timeline Annual Annual Annual

Mandatory

Quality Programs –Above and Beyond BPCI/CCJR

Bonuses

30 Day

Readmits

% at Risk 3% 1% 1.75%

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

Affordable Care Act Penalty Avoidance

2016 -Up to 6.75 % of total Medicare FFS Inpatient revenues hospital

wide potentially at risk

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

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.

10/5/2015

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-CAUTI-

CLABSI-SSI)(40%), Medicare spending per beneficiary-Efficiency (25%)

Quality Programs - Affordable Care Act

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 Re-

design

•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.

10/5/2015

All Medicare Part A / B fee-for-service payments

Rehabilitatio

n and

Recovery

Acquisition Cost /

Hospital

Efficiencies

Long Term

Follow Up

‘Prehab’

Phase

Medicare FFS Part A and B Breakdown of Cost Across Care Continuum THA (2011-2013).

One more look at TJA cost drivers…

Admission Discharge 90 Day 10 Year

90 days

•Implant and

Device

Acquisition

•Hospital Fees

•LOS

•Physician Fees

•Post-Acute Care and Rehabilitation

•Readmission Costs

•Facility Costs (SNF, Home Health)

Know Your Why

1 “Shifting From Volume to Value, AAOS Bundled Payment Summit, 5/28/15, Washington, DCJim Weinstein, MD –CEO of Dartmouth-

Hitchcock

Simon Senick , https://www.youtube.com/watch?v=sioZd3AxmnE

Thank you!

The Successful Future Of TKA Digging Your Way Through Bundle Syllabus

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