Bundled Payments Model Utilizing Clinical Pathways a Success for Hip and Knee Replacements

A Bundled Payments for Care Improvement model developed at New York University Langone Medical Center (NYULMC), New York City, NY, was successful at improving institutional efficiency and providing more value for patients. 

Hip and knee replacements are common procedures among hospitals in the United States, representing the highest volume of inpatient surgeries for Medicare beneficiaries and costing the health care system more than $7 billion in 2014 alone. To help manage these costs, the Centers for Medicare and Medicaid Services (CMS) instituted the BPCI initiative in 2011, which aimed to provide higher quality, more coordinated care at a lower cost. 
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In a study published in The Journal of Arthroplasty, researchers, who were led by Nicholas J Bolz, BS, NYULMC, highlighted their experiences implementing a BPCI program during 2013-2014 at their institution.

To ensure the success of the model, hospital staff recognized the need for a more streamlined approach to patient management that would allow for better monitoring and control of all three phases of the episode of care: prehospitalization, inpatient care, post-acute care. To do so, they developed a comprehensive evidence-based pathway for proper patient oversight that they believed would apply to 90% of all patients. The pathway utilized nurse practitioners, clinical care coordinators, and doctors, to ensure that the care provided is multidisciplinary and smoothly transitions patients through the 3 phases. 

The researchers also developed a risk stratification model that helped them to better optimize presurgery procedures and identify patients who were most at risk for rehospitalization, a major driver of high health care costs. Risk factors such as obesity, illness, and comorbidities were monitored carefully, and patient surgery was delayed if these risk factors were deemed too significant or dangerous to proceed. 

In its first year of eligibility, the BPCI program successfully enrolled 731 patients. Overall, average length of stay for patients treated on the program (2013, 3.5 days; 2014, 3.2 days) was significantly shorter than the average length of stay observed in the 3 years prior to its implementation (2009, 5.31 days; 2010, 4.60 days; 2011, 4.43 days). Patients were also more often discharged to self-care and to home with health care assistance compared with those not on the program (3% vs 33% of patients in 2012; 11% vs 67% in 2014).

Readmission rates were also more efficiently managed, falling to just 6% in the first quarter of 2014, compared with 10%, 15%, and 14% readmission rates in the 3 consecutive years prior to use of the program.

“NYULMC has successfully implemented value-based purchasing through the use of the BPCI 2 model,” authors of the study concluded. “Since January 2013, NYULMC has achieved a significant decrease in patients’ length of stay, discharge to inpatient facilities, and cost of the episode of care.”

In accordance with the success of the program, and with awareness of its limitations, CMS introduced the Comprehensive Care for Joint Replacement in April 2016, which they hope will do even more to encourage cooperation among providers, improve the quality of care, and provide more value to patients.—Sean McGuire 

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Bolz NJ, Iorio R. Bundled Payments: Our Experience at an Academic Medical Center. J Arthroplasty. 2016;31(5):932-935.