Rapid Recovery in Total Joint Arthroplasty. Contemporary Strategies 9783030412227, 9783030412234

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Rapid Recovery in Total Joint Arthroplasty Contemporary Strategies Giles R. Scuderi Alfred J. Tria Fred D. Cushner Editors

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Rapid Recovery in Total Joint Arthroplasty

Giles R. Scuderi  •  Alfred J. Tria Fred D. Cushner Editors

Rapid Recovery in Total Joint Arthroplasty Contemporary Strategies

Editors Giles R. Scuderi Northwell Orthopedic Institute New York, NY USA

Alfred J. Tria The Orthopaedic Center of New Jersey Somerset, NJ USA

Fred D. Cushner Hospital for Special Surgery New York, NY USA

ISBN 978-3-030-41222-7    ISBN 978-3-030-41223-4 (eBook) https://doi.org/10.1007/978-3-030-41223-4 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

For a long time, total joint arthroplasties were performed as inpatient procedures at hospitals with length of stay extending to several days followed by transfer to a rehabilitation facility and later home health care. However, this trend has now changed with advances in surgical technique, anesthesia, and pain control. Rapid recovery programs have now reduced the hospital length of stay to less than two days for many uncomplicated cases, and there is also a movement to perform total joint arthroplasties in an outpatient facility, especially for younger and healthy patients. This change requires surgeons and administrators to implement the improved clinical processes and learn from successful programs to avoid unnecessary complications and readmissions. This emerging change in total joint arthroplasty is also driven by patients and payers, who desire to reduce their costs, increase convenience and satisfaction, and decrease the risk of postoperative complications. In addition, more hospitals are moving total joint surgeries to outpatient settings to compete with freestanding ambulatory surgery centers. Moving these procedures to outpatient facilities will have a financial impact on hospitals, especially as the Centers for Medicare & Medicaid Services (CMS) removes total knee and total hip arthoplasties from the inpatient-only list. Commercial health insurance companies are also implementing similar changes in the rules. These changes create new pressures on all the health-care providers in the system. Surgeons will need to collaborate with the hospital, and administrators will need to be agile to execute change. This text serves as a practical guide for each member of the team with insights by the leading authorities from around the country that have experience in rapid recovery and outpatient programs. While there is a move toward outpatient surgery, there is still a need for inpatient hospital procedures. Contributors will also provide information on differentiating the patient population. We are hopeful that readers will find this information helpful as they react to the changing world for total joint arthroplasty. New York, NY, USA  Giles R. Scuderi Somerset, NJ, USA  Alfred J. Tria New York, NY, USA  Fred D. Cushner v

Contents

1 The Changing World of Total Joint Arthroplasty ��������������������������������    1 Giles R. Scuderi 2 Understanding Alternative Payment Models����������������������������������������   13 Adam J. Schwartz and Kevin Bozic 3 Insurance Contracting for Outpatient Arthroplasty Programs����������   31 Adam E. Roy, Owen R. O’Neill, and Richard Iorio 4 Creating a Limited Stay Total Joint Program��������������������������������������   47 Craig McAllister, Vinod Dasa, Brandon Kent, and Michael Langley 5 Preparing your Your ASC for Same-Day Joint Replacement��������������   65 David A. Crawford and Keith R. Berend 6 Preparing Your Hospital for Same-Day Joints��������������������������������������   75 David A. Crawford and Adolph V. Lombardi Jr. 7 Patient Risk Assessment and Optimization ������������������������������������������   83 R. Michael Meneghini and Leonard T. Buller 8 Enhanced Recovery After Surgery (ERAS): The Changing Practice����������������������������������������������������������������������������   91 Christopher Campese, Jeremy Asnis, and Ezra Kassin 9 The Preoperative Clinical Pathway��������������������������������������������������������  115 Asa Shnaekel, Jeffrey Stambough, Paul Edwards, C. Lowry Barnes, and Simon Mears 10 Postoperative Clinical Pathways for Outpatient Arthroplasty of the Hip and Knee ��������������������������������������������������������������������������������  153 Ajay Premkumar, Fred D. Cushner, and Michael Ast 11 Anesthesia Considerations����������������������������������������������������������������������  165 Nishant A. Shah, Erdan Kayupov, and Ritesh R. Shah

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12 Efficiency in Hip Surgery������������������������������������������������������������������������  185 Luke J. Garbarino, Peter A. Gold, and Jonathan R. Danoff 13 Efficiency in Knee Surgery����������������������������������������������������������������������  211 Dexter K. Bateman, Robert W. Dow, and Alfred J. Tria 14 The Place for Innovative Technology ����������������������������������������������������  229 Hytham S. Salem, Kevin B. Marchand, Kevin K. Mathew, John M. Tarazi, Joseph O. Ehiorobo, and Michael A. Mont 15 Multimodal Pain Management Strategies in Total Joint Arthroplasty����������������������������������������������������������������������  239 Benjamin M. Wooster and Mark W. Pagnano 16 Immediate Postoperative Rehabilitation ����������������������������������������������  255 Tony George, Ali Mostoufi, Bobby Oommen, Carolyn Yuse, and Didier Demesmin 17 Achieving Milestones in Post-acute Rehabilitation������������������������������  271 Tony George, Ali Mostoufi, Carolyn Yuse, and Timothy Tiu 18 Skilled Nursing Facilities: It Is a Shared Partnership��������������������������  285 John R. Steele and Michael P. Bolognesi 19 Patient Surveillance in Total Joint Arthroplasty����������������������������������  295 Andrew Luzzi, Andrew Fleischman, and Javad Parvizi 20 Achieving Satisfaction with Patient-­Reported Outcomes: PROMS����  311 Elizabeth P. Davis, Adam M. Freedhand, David Rodriguez-Quintana, and Philip C. Noble 21 Choosing Institutional Metrics ��������������������������������������������������������������  329 Jenna Bernstein, Joshua Rozell, and Joseph Bosco 22 The Use of Evidence for Process Improvement������������������������������������  337 Nathanael D. Heckmann, Charles P. Hannon, and Craig J. Della Valle Index������������������������������������������������������������������������������������������������������������������  347

Contributors

Jeremy  Asnis, MD  North Shore University Hospital at Manhasset, Northwell Health System, Manhasset, NY, USA Michael Ast, MD  Hospital for Special Surgery, New York, NY, USA C.  Lowry  Barnes, MD  Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Dexter  K.  Bateman, MD  Department of Orthopaedic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA Keith R. Berend, MD  JIS Orthopedics, New Albany, OH, USA Jenna Bernstein, MD  Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY, USA Michael  P.  Bolognesi, MD  Duke University Medical Center, Department of Orthopaedic Surgery, Durham, NC, USA Joseph Bosco, MD  Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA Kevin  Bozic, MD, MBA  Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX, USA Leonard T. Buller, MD  Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Christopher  Campese, MD, MA, MS, FASA  Department of Anesthesiology, Glen Cove Hospital, Northwell Health System, Glen Cove, NY, USA David A. Crawford, MD  JIS Orthopedics, New Albany, OH, USA Fred D. Cushner, MD  Hospital for Special Surgery, New York, NY, USA Jonathan  R.  Danoff, MD  Department of Orthopaedics, Northwell Health, New Hyde Park, NY, USA ix

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Vinod Dasa, MD  Department of Orthopedics, LSU Health Sciences Center, New Orleans, LA, USA Elizabeth P. Davis, MD  Department of Orthopaedic Surgery, University of Texas Health Sciences Center at Houston McGovern Medical School, Houston, TX, USA Craig  J.  Della  Valle, MD  Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA Didier  Demesmin, MD  Department of Pain Medicine, St. Peters University Hospital, Somerset, NJ, USA Robert W. Dow, MD  Department of Orthopaedic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA Paul Edwards, MD  Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Joseph  O.  Ehiorobo, MD  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Andrew  Fleischman, MD  Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA Adam  M.  Freedhand, MD  Department of Orthopaedic Surgery, University of Texas Health Sciences Center at Houston McGovern Medical School, Houston, TX, USA Luke  J.  Garbarino, MD  Department of Orthopaedics, Northwell Health, New Hyde Park, NY, USA Tony George, MD  Department of Physical Medicine and Rehabilitation, St Peters University Hospital, New Brunswick, NJ, USA Peter  A.  Gold, MD  Department of Orthopaedics, Northwell Health, New Hyde Park, NY, USA Charles  P.  Hannon, MD  Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA Nathanael  D.  Heckmann, MD  Adult Reconstruction Division, Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA Richard Iorio, MD  Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA Ezra Kassin, MD  Long Island Jewish Medical Center, Northwell Health System, Lake Success, NY, USA Erdan Kayupov, MD  Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, IL, USA

Contributors

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Brandon  Kent, MD  Department of Orthopedics, LSU Health Sciences Center, New Orleans, LA, USA Michael Langley, MD  Department of Orthopedics, LSU Health Sciences Center, New Orleans, LA, USA Adolph V. Lombardi Jr., MD, FACS  JIS Orthopedics, New Albany, OH, USA Andrew Luzzi, MD  Department of Orthopedic Surgery, NewYork-Presbyterian/ Columbia University Medical Center, New York, NY, USA Kevin B. Marchand, BS  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Kevin K. Mathew, BS  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Craig  McAllister, MD  Department of Orthopedics, The Everett Clinic, Kirkland, WA, USA Simon  Mears, MD, PhD  Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA R.  Michael  Meneghini, MD  Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA Michael A. Mont, MD  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Ali Mostoufi, MD  New England Spine Care Associates, Cambridge, MA, USA Department of PM&R, Tufts University, Boston, MA, USA Boston Regenerative Medicine, Boston, MA, USA Philip  C.  Noble, PhD  Department of Orthopaedic Surgery, University of Texas Health Sciences Center at Houston McGovern Medical School, Houston, TX, USA Owen R. O’Neill, MD  Department of Orthopedics, Sports Medicine, Twin Cities Orthopedics PA, Edina, MN, USA Bobby  Oommen, MD  Department of Physical Medicine and Rehabilitation, Champlain Spine and Pain Management, Champlain Valley Physicians Hospital, Plattsburgh, NY, USA Mark  W.  Pagnano, MD  Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Javad Parvizi, MD/FRCS  Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA Ajay  Premkumar, MD, MPH  Hospital for Special Surgery, New York, NY, USA

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David Rodriguez-Quintana, MD  Department of Orthopaedic Surgery, University of Texas Health Sciences Center at Houston McGovern Medical School, Houston, TX, USA Adam E. Roy, MD  Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, USA Joshua Rozell, MD  Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY, USA Hytham S. Salem, MD  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Adam J. Schwartz, MD, MBA  Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA Giles R. Scuderi, MD  Northwell Orthopedic Institute, New York, NY, USA Nishant A. Shah, MD  Illinois Sports Medicine and Orthopedic Surgery Center, Midwest Anesthesiology Partners, Advocate Lutheran General Hospital, Chicago, IL, USA Ritesh R. Shah, MD  Advocate Illinois Masonic Medical Center, Hip Arthroscopy, Hip & Knee Replacement, Illinois Bone and Joint Institute, LLC, Chicago, IL, USA Asa  Shnaekel, MD, MPH  Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Jeffrey  Stambough, MD  Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA John R. Steele, MD  Duke University Medical Center, Department of Orthopaedic Surgery, Durham, NC, USA John M. Tarazi, MD  Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA Timothy Tiu, MD  Department Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA Alfred J. Tria, MD  The Orthopaedic Center of New Jersey, Somerset, NJ, USA Benjamin  M.  Wooster, MD  Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Carolyn  Yuse, MD  Department of Rehabilitation Services, Board Certified Clinical Specialist in Geriatric Physical Therapy, Brigham and Women’s Hospital, Boston, MA, USA

Chapter 1

The Changing World of Total Joint Arthroplasty Giles R. Scuderi

Introduction The incidence of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) has been steadily increasing over the last few decades with over one million THA and TKA procedures performed each year in the United States. With the aging of the “baby boomers,” the higher rates of diagnosis and treatment of degenerative arthritis, and the growing demand for improved mobility and quality of life, the incidence of THA and TKA will continue to rise, making these procedures the most common elective surgical procedures in the coming years [1–3]. It was observed that the number of adults in the United States undergoing TKA increased by 143% from 2012 to 2015 [4]. It is anticipated that future increases in both THA and TKA will occur in both inpatient and outpatient settings, although the majority of the growth is expected in the outpatient setting with only a modest increase in the inpatient setting [5, 6]. This shift to the outpatient setting is further supported by the 2018 Outpatient Prospective Payment System rule released in 2017 by the Centers for Medicare and Medicaid Services (CMS), in which TKA was removed from the inpatient-only list. In light of these changes, the orthopedic community of arthroplasty surgeons responded with the creation of safe and cost-efficient value-based outpatient programs that optimize patient management and manage all necessary components within the episode of care. THA and TKA are some of the most common elective procedures, and both have led to significant improvement in health-related quality of life [7]. Unchecked with increased utilization, healthcare costs would rise exponentially. Curbing the continuing increase in healthcare costs has led to innovative cost- containment solutions. The fee-for-service model was targeted as a cause of the steady rise in healthcare spending because it provides incentive to provide more rather than G. R. Scuderi (*) Northwell Orthopedic Institute, New York, NY, USA © Springer Nature Switzerland AG 2020 G. R. Scuderi et al. (eds.), Rapid Recovery in Total Joint Arthroplasty, https://doi.org/10.1007/978-3-030-41223-4_1

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better care. In 2013, the Bundled Payments for Care Improvements (BPCI) initiative was launched by CMS.  This created a shift from a volume-based model to a value-based model that rewards value and quality encompassing the complete episode of care. As a separate but related value-based payment model, CMS introduced the Comprehensive Care for Joint Replacement (CJR) program. In addition, based upon the success and merits of the bundle programs, some of the nation’s largest self-­insured employers are aligning with centers that provide the highest quality and value of care. This value-driven model has also extended to patients who are now empowered with more information and data enabling them to make an educated decision on their healthcare. These alternative payment models continue to evolve and have facilitated a shift toward collaborative multidisciplinary team-based approaches to THA and TKA episodes of care that are patient-centered value-based systems. This new value-based model has the potential to provide an episode of care with little variation. These patient-centric programs strive to reduce nonessential operating room and hospital services; minimize adverse events requiring increased length of stay, readmission, and discharge to inpatient rehabilitation facilities; and ultimately better coordinate inpatient and outpatient services. This has also placed further burden on the hospitals to be more responsible for healthcare. The Affordable Care Act (ACA) introduced the Hospital Acquired Condition Reduction Program (HACRP) holding hospitals accountable for hospital-acquired complications. This is part of the Medicare pay-for-performance program, which supports CMS efforts linking payment to quality during inpatient stay and reduces hospital-acquired complications. While these value-based programs have affected a deal of change, they are not without some unforeseen consequences. The issue with the CMS bundle programs is that they are neither risk stratified nor risk adjusted. Patients with chronic illnesses or multiple comorbidities require more services and extended care than healthier patients. Therefore, there is the potential for some surgeons or hospitals to “cherry pick” or “lemon drop” patients with multiple comorbidities [7]. Attention should be given not to exacerbate healthcare disparities as surgeons perform more total joint arthroplasty (TJA) on the healthier low-risk patients and limit access of surgery to the higher risk patients. Additionally, hospitals need to financially plan for the shift of the healthier patients to the outpatient setting, while the higher risk patients with chronic illnesses or multiple comorbidities undergo surgery at the hospital with longer periods of hospitalization and increased cost. Navigating these situations requires clinical insight and administrative leadership. Effectiveness of the programs relies on the adoption of evidence-based practices and the support of surgeon champions. The arthroplasty surgeon needs to maintain responsibility for patient care throughout the episode, from the preoperative workup to the surgery to the postoperative care, including hospitalization and rehabilitation, home care, and finally office follow-up. A patient’s risk for a negative outcome following surgery may be both predetermined and modifiable prior to surgery. This necessitates a redesign of total joint arthroplasty (TJA) programs with a surgeon-led multidisciplinary team consisting of anesthesiologists, internal medicine consultants, pain management, nursing, physical therapists, postacute

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services, case managers, and hospital administration. The traditional model of a patient undergoing surgery after receiving “medical clearance” has evolved into a shared decision-making process with patient optimization managed by this multidisciplinary team. This team approach incorporates the entire episode of care with the intention of optimizing the patient for surgery with management or correction of modifiable risk factors, enhancing the recovery period with early ambulation, achieving adequate pain control, decreasing length of stay, reducing complications and readmissions, and increasing discharge to home. While most of the attention has focused on addressing preoperative modifiable risk factors such as smoking, malnutrition, and obesity, a recent study has shown that nonmodifiable comorbidities such as congestive heart failure, pulmonary circulation disorders, renal disease, cardiac arrhythmia, chronic pulmonary disease, and neurologic disorders have a greater impact on achieving the postoperative goals and may be more substantial contributing factors impacting the outcome of the surgery and the associated increased cost [8]. This is impactful since as programs further optimize the patient prior to or during the episode of care, “rapid recovery” or “fast-track” programs have become popular. These programs have significantly reduced the length of stay, and patients who meet appropriate criteria are discharged home either the next day or on the same day of surgery [9, 10]. What has also happened is that these rapid recovery programs have created a natural evolution from the inpatient to the outpatient setting [11–15]. While outpatient TJA is not a new concept, there has been a slow migration to wide acceptance because there is not a proven method for confidently identifying patients who can safely undergo outpatient TJA. The American Association of Hip and Knee Surgeons (AAHKS) in 2018 released a position statement on outpatient joint replacement. It is recommended that gradual and thoughtful changes in practice be influenced by defined quality metrics, including length of stay, readmission rates, complication rates, and general health of the patient population. This necessitates a thoughtful analysis of quality metrics by both surgeons and hospital administration. From a practical point, if a surgeon or hospital has a length of stay of 2 days or more following THA or TKA, it is not advisable that the surgeon or hospital begin performing outpatient TJA until they have gained experience in reducing their length of stay to less than 2  days. Reviewing institutional data, improving relevant metrics, and optimizing clinical protocols to maintain patient safety are fundamental to gaining experience. The essential elements required for a successful program include patient selection, patient education and expectation management, social support and environmental factors, clinical and surgical team expertise, and hospital or surgery center factors.

Patient Selection With the changing milieu of TJA to an outpatient setting, establishing patient selection criteria is critical. The only way to ensure a consistent and manageable episode of care is to have every patient undergo a detailed risk assessment prior to surgery.

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This information helps determine whether the patient is a suitable candidate for outpatient TJA or better managed as an inpatient. Currently, while there are recommendations, there are no universally accepted guidelines for risk assessment prior to determining which patient would be suitable for outpatient TJA. Previously established scoring systems used by the medical community have been used as surrogates for risk assessment. The American Association of Anesthesiologists Physical Status Classification System (ASA-PS) and the Charlson Comorbidity Index (CCI) have been explored for patient risk stratification, but their appropriateness for selecting outpatient TJA patients is unproven and their predictive value is low when evaluating TJA patients. With the need for a more arthroplasty-specific and predictive medical risk assessment score to safely select patients to minimize risk and optimize outcomes, the Outpatient Arthroplasty Risk Assessment (OARA) score was developed [11]. The OARA score was found to more accurately predict safe early discharge after TJA than the ASA-PS or CCI. Similarly, the readmission risk assessment tool (RRAT) is another method of risk stratification for patients undergoing TJA that is based on modifiable risk factors and comorbidities [16, 17]. The RRAT score has been associated with readmission after TJA but was not designed to identify patients at risk for perioperative complications that would necessitate readmission after outpatient TJA. Regardless of the risk assessment score used, significant predictors of adverse perioperative events include chronic obstructive pulmonary disease, history of cerebral vascular accident or transient ischemic attack, prior myocardial infarction or other cardiac surgery, hypertension, overweight body mass index, smoking, anxiety, and prolonged operative time. Accurate risk assessment that is performed prior to surgery is an essential component of safe patient selection for outpatient and early discharge TJA. Modifiable risk factors must be addressed preoperatively to optimize the patient for surgery and determine the planned clinical care pathway.

Patient Education and Management An essential element in the clinical pathway is patient education with a clear understanding and alignment of both surgeon and patient expectations. The first step in the preoperative pathway begins with a clear and insightful discussion about length of stay and discharge disposition, as well as the inclusion criteria for outpatient and early discharge TJA.  A preoperative multidisciplinary TJA education class is an effective method for introducing patients to the planned clinical pathway and to a total joint coordinator or case manager who is assigned to the TJA program. This is also an opportunity to ensure that the necessary staff and service line resources are available and are coordinated successfully. In addition to patient education, it is important that the patient has a home support structure, so a family or “coach” education program is essential and should outline the expectations and necessary home environment for an optimal and safe patient recovery following discharge. When applicable, the TJA coordinator should do a patient home assessment to make ­certain that the family member or home care provider is competent to tend to the

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needs of the patient in the first 48–72 h postoperatively. The ability to identify and avoid potential challenges in the perioperative period following TJA is important for improving patient satisfaction, reducing complications, and ultimately providing improved value for the episode of care. Since the early postoperative observational period is shifting to the home environment, same-day discharge and next-day discharge following THA and TKA necessitate closer patient surveillance after surgery. The patient must have adequate physical and social support during the early postoperative period at home and have full access to the medical and surgical team 24 h a day and 7 days a week until the patient sufficiently recovered. Rapid recovery programs have transitioned patient supportive care and guidance from the hospital staff to the surgeon’s staff. Traditionally, during an extended hospital stay, there are a multitude of healthcare providers, including physicians, medical consultants, floor nurses, nursing aides, social workers, physical therapists, occupational therapists, and dieticians who interact with the patient. The process of “rounding” on patients after surgery to observe their recovery has changed. When patients leave the hospital on the same day or the next day, the burden of care during the postoperative period falls onto the surgeon, office staff, nurse navigators, home care service providers, and family [18, 19]. Most programs structure the postoperative management based on the resources available. The challenge is that as the need for postoperative resources increases with more individuals involved in the care, the cost increases and the value decreases. By deploying solutions like web-based navigation and education, telehealth, and asynchronous communication, programs can provide postoperative care more effectively. This is further enhanced by the adoption of a series of mechanisms to manage the early days following discharge, including nonstandard office or telemedicine visits on the early days after discharge, evaluation through home visiting nurse services, and close telephone conversations. Nurse navigators using digital formats such as web-based patient portals with smartphones, tablets, or computers can also perform virtual patient rounds. These nurse navigators provide a coordinated pathway for patients guiding discharge disposition and home needs [20]. Reports have shown that early engagement by these means has reduced patient emergency room visits, readmissions, and reoperations [18]. Digital services with nurse navigators help establish a TJA program that provides patient communication services during and after office hours [21]. The office staff, including physician extenders, secretarial staff and nurse navigators, who are trained on appropriate care, can address calls during the day, but TJA surgeons or surgical mid-level providers, such as nurse practitioners or physician assistants, should address after-hour phone calls. These providers can resolve the majority of after-hour calls with reassurance or advice, reducing visits to the emergency room. As mentioned above, web-based patient portals have been useful in navigating and guiding patients through the perioperative period with the potential for real-time communication with an enhanced recovery experience. The introduction of digital technology has enhanced patient care. By offering targeted education, communication tools, and patient-reported outcome (PRO) ­collection, web-based portals encourage patients’ engagement in their own care.

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Web-­based portals provide the ability to guide the patient through a personalized care plan, engage in real-time patient monitoring, and facilitate outcome collection. In the TJA population, web-based portals may serve the unique benefit of offering online physical therapy, allowing TJA patients to reach functional goals while reducing costs. Implementation of an online physician-patient messaging platform also allows patients to communicate with providers efficiently, enabling rapid follow-­up for wound abnormalities or providing reassurance and preventing unnecessary visits for normal-appearing wounds [22]. Continued efforts are underway to build web-based patient platforms where patient optimization can be performed efficiently to generate individualized patient-centric programs that can be delivered via mobile applications and tracked within the electronic health record.

Multidisciplinary Team Expertise A critical element in performing outpatient or early discharge TJA, whether in a hospital or in an ambulatory surgery center (ASC), is a capable and experienced medical and surgical team. The anesthesia team, surgical team, and recovery room nursing staff must be experienced and facile in perioperative pain control, fluid resuscitation, early patient mobilization, and medical management. Enhanced recovery after surgery (ERAS) is becoming a critical element in rapid recovery programs. ERAS is a multidisciplinary endeavor directed toward the modulation of the stress of surgery [23]. Chief components of the program are preoperative patient education to reduce anxiety and emotional stress, adequate multimodal analgesia, and early mobilization after surgery. Preoperative education most benefits patients with depression, anxiety, unrealistic expectations, and limited social support. Recent changes in preoperative fasting and carbohydrate loading are impacting postoperative recovery. ERAS guidelines permit the intake of clear fluids until 2 h before the induction of anesthesia and a 6-h fast for solid food [24]. Guidelines also recommend that patients consume a clear carbohydrate-rich drink 2–3 h prior to surgery with the goal of the patient presenting to surgery in a metabolically anabolic state. While there is some controversy that preoperative carbohydrate loading contributes to an improved outcome following TJA, the risk versus benefits of liberal fasting and carbohydrate loading suggests that these concepts can be safely applied to TJA. Multimodal pain management has become the standard of care for TJA [25, 26]. Pain management and anesthesia protocols tend to be a collaborative effort between the anesthesiologist and the surgeon with the goal of providing effective pain control; minimizing adverse reactions to the anesthesia, such as nausea; and allowing early and rapid mobilization after surgery. Regional anesthesia, peripheral nerve blocks, and periarticular injections have been effective modalities. Reduced length of stay is consistently associated with the use of neuraxial regional anesthesia versus general anesthesia. Multimodal analgesia techniques are individualized for each patient and may incorporate several methods of pain relief. The concern

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about the opioid crisis had led surgeons to reevaluate the extended use of narcotics following surgery. Opioid use is decreasing in patients undergoing TJA, which may be in part due to an increase in multimodal analgesia, along with the use of nonnarcotic medications. Improving prescribing practices, along with the implementation of governmental policies and registries, has further impacted postoperative opioid use. Efficiency in the operating room centers on a choreographed approach, with each team member knowing his or her responsibility. Time is a valuable resource. A delay in the start time, a lengthy turnover, or time spent looking for missing equipment can impact operating room efficiency. Personal accountability, streamlining of procedures, interdisciplinary teamwork, and accurate data collection influence reproducible outcomes with minor variation. Efficiency leads to a reduction in the operative time, which ultimately has been shown to decrease the length of patients’ stay [27].

Hospital and Ambulatory Surgery Centers Rapid recovery programs have shifted some TJA cases from the inpatient to the outpatient setting with the establishment of dedicated ASCs. Performing outpatient TJA in an ASC requires an efficient and streamlined operating room and perioperative process, which should be validated within an inpatient setting prior to moving cases to ASC. It has been shown that patient-related, procedural-related, and institutional-­ related risk factors have been shown to influence the length of stay following TKA [28]. Just like patient optimization, institutional optimization, standardization, and adherence to established clinical pathways are necessary for a limited stay or outpatient TJA. Aside from the surgical technique and anesthesia protocols, surgical staff training is vital for the success of outpatient TJA. The staff should be trained and should be competent with the surgeon’s surgical setup, technique, and instrumentation. Operating room efficiencies should focus on surgeon preferences and procedure requirements to “right size” the instrument trays and limit the burden on central sterilization. It is also important that timely turnover of the operating room be performed to maximize utilization and patient throughput. When system processes are put in place, surgeon confidence, along with team confidence, increases. Standardization of surgical protocols decreases the setup time, reduces procedure time, and reduces the costs associated with instrument sterilization and central processing. With the appropriate infrastructure in place and appropriate patient selection, outpatient TJA can be a safe, efficient, and cost-saving procedure for hospitals and ASCs. The financial implications are continuing to evolve with savings on both institutional direct and indirect costs with an ultimate reduction in charges. Recent reports have shown a decrease in charges to the patient and insurer with outpatient TJA without a significant increase in complications or readmissions [6, 29, 30].

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With this shift of TJA to the outpatient setting, there is an anticipated increase in joint ventures between hospitals and ASCs. Hospitals will need to look at outpatient facilities to capture lost revenue as the inpatient volume decreases. Private equity firms have also begun to invest capital into ASCs, realizing that there is an opportunity to further expand the outpatient market. Regulatory agencies such as the Joint Commission and CMS have begun the review of the accrediting process for ASCs, and recently CMS has approved the performance of TKA in the ASC setting.

Innovative Technology Over the years, new innovative technologies and implant designs, including new bearing surfaces, patient-specific instrumentation, computer and handheld navigation systems, intraoperative sensors, and robotics, have impacted the world of TJA.  These new innovations have been scrutinized for their safety, efficacy, and cost-effectiveness. Since they almost always come with a substantial rise in cost compared to conventional techniques and predicate implant designs and the benefits of the technology may not be recognized for decades, surgeons, hospital administrators, and industries must analyze the business plan and restrategize their approach to the introduction of these technologies. This is especially important with the initiation of bundled payments that concentrate on short-term savings for the episode of care, newer and more expensive technologies are challenging the system. At the current reimbursement under bundled payments, advocates of innovative technologies will have to demonstrate the increased value to cover the increased cost. Within the competitive marketplace of TJA, surgeons may feel the pressure to be relevant by adopting new technologies requested by their patients or presented to them by industry representatives. Any new innovation needs to demonstrate its intended benefits. This can only be accomplished if surgeons document their results with satisfactory medical records and PROs. Innovative technologies will continue to shape TJA, but surgeons should not become dependent upon new technology.

Supply Chain Management As part of a value-based care system, there is a need for a partnership between the surgeon and the hospital or ambulatory surgery center. The intention is to provide a standard of care and identify conversion opportunities, such as implants, innovative technology, medical supplies, and pharmacy products. Facilitating surgeon independence and encouraging the use of cost-effective products with clinically equivalent outcomes are core elements of a successful partnership. Once a standardized program is implemented, feedback and data analysis on the clinical, financial, and operational elements should be performed to assure efficacy and success.

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Routine metrics should cover financial and operational elements of the program and ­continually look at opportunities for improvement and innovation. This can be organized with enterprise resource planning that provides an interactive view of operational activities, including implant costs, pharmaceutical costs, usage, and revenue cycle processes; a complete picture with the alignment of procedure costs with DRG reimbursement; and an alignment of the cost data with the clinical outcome data.

The Workforce Trends Workforce management ensures that the right people are in the right place at the right time. In healthcare and in the treatment of the growing population of patients with arthritis, this is a complex process. Current orthopedic training necessitates a minimum of 10 years, from medical school to completion of an orthopedic residency program. In addition, fellowship training adds an additional 1–2 years, with specialty training. Planning for the future must take this into account, along with the changing patient population, since there is a well-documented increase in the number of patients suffering from osteoarthritis [31]. Moreover, one must take into account future changes in TJA as a result of an aging population, technologic advances, and demand for revision surgery. As highlighted above, the number of TJA cases has sustained continued growth over the years. For this trend to continue, the skilled surgical workforce must meet procedural demands. The challenge is that despite the increase in TJA cases, the number of adult reconstruction surgeons is decreasing [32]. This can be potentially reversed by increasing the efficiency of surgeons per case, delaying the retirement of skilled arthroplasty surgeons, and increasing the complement of graduating residents with fellowship training in TJA. However, there is not a simple solution for this workforce supply-side dilemma. Governmental agencies, health care economists, and patients need to understand that the current number of arthroplasty surgeons will be unable to meet the TJA needs of the growing arthritic population [33]. There is no clear-cut solution to this problem. It has been postulated that some of the solutions are practical, and others are unrealistic or unlikely. These ideas include the following: (1) allow limited access to play out, but this will result in rationing TJA with long waiting times similar to those seen in socialized healthcare systems; (2) train more arthroplasty surgeons to meet the demand, but this would mean increasing the number of orthopedic residency and fellowship programs beyond the current complement; (3) increasing reimbursement for TJA would incentivize surgeons, but this goes counter to the current declining reimbursement for surgery; (4) with the increasing number of Medicare patients, allowing participating surgeons to balance bill similar to nonparticipating surgeons is appealing, but this would require governmental changes that are unlikely; and (5) a final proposal would be to change the certificate of need and specialty hospital regulations to allow the development of

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high volume, efficient TJA centers [30]. The final solution has yet to be identified, but changes are happening. There has been a recent increased interest in adult reconstruction fellowships among graduating residents because of increasing employment opportunities and marketability [34]. This will help increase the complement of skilled arthroplasty surgeons. Another change is that while the majority of TJAs are still performed in an inpatient hospital setting, there has been a dramatic increase in the number of ASCs. Hospitals recognizing this shift have acquired or formed joint ventures with ASCs. This has also allowed for a three-way partnership between the hospitals, surgeons, and the ASC management organization. Physician-­owned specialty hospitals and ASCs have also provided a financial incentive to move healthy TJA patients to the outpatient centers. Surgeons have begun to move patients to ASCs because of high quality of care, lower cost of care, and better reimbursement. Until there is financial neutrality, it may be more lucrative for some surgeons to perform TJA in an ASC. This has also created another dilemma: hospitals will acquire the “sicker” patients who require greater care in the perioperative period with higher costs. Hospitals participating in Medicare’s mandatory and voluntary bundled payment programs for TJA are unsure whether CMS will ultimately adjust the payments to account for a higher proportion of sicker, higher cost patients remaining in inpatient units while healthier individuals move to outpatient settings.

Summary In the coming years, there will be further changes to performing TJA. While CMS has already moved TKA from the inpatient-only list, there are plans to move THA from the inpatient-only list, making the procedure eligible for Medicare reimbursement in the hospital outpatient and inpatient setting. CMS is also proposing that TKA be added to the ASC-covered procedure list, expanding the surgeons’ choice for the appropriate setting for the care of their patients. These moves by CMS reflect the strides that have been made in patient selection criteria and clinical pathways for patients undergoing TJA as outpatients in either hospitals or ASCs. It is also anticipated that commercial insurers will also follow the lead of CMS. Execution of outpatient TJA will require appropriate patient selection and education, efficient surgical technique with tailored anesthesia, excellent medical care, and coordinated postoperative care. Surgeons, hospitals, and ASCs will need to focus on patient experience with third-party metrics. However, the entire medical community, the government, and the insurers need to realize that both THA and TKA are complex procedures that are performed on a diverse sociodemographic patient population with varying age-related comorbidities. Improvements in surgical techniques and perioperative care have reduced the length of stay, but the criteria of discharge between inpatient and outpatient TJA do not differ. Medical comorbidities, social support, and environmental factors must be considered in determining the safest and appropriate setting for each patient.

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References 1. Kremers HM, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg. 2015;97:1386–97. 2. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ.  Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606–12. 3. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among total knee beneficiaries, 1991–2010. JAMA. 2012;308(12):22–8. 4. Inacio MCS, Paxton EN, Graves SE, Namba RS, Nemes S.  Projected increase in total knee arthroplasty in the United States–an alternative projection model. Osteoarthr Cartil. 2017;25(11):1797–803. 5. Gogineni HC, Gray CF, Prieto HA, Deen JT, Boezaart AP, Parvataneni HK.  Transition to outpatient total hip and knee arthroplasty: experience at an academic tertiary care center. Arthroplast Today. 2019;5:100–5. 6. Bert JM, Hooper J, Moen S. Outpatient total joint arthroplasty. Curr Rev Musculoskelet Med. 2017;10:567–74. 7. Humbyrd CJ. The ethics of bundle payments in total joint replacement: “cherry picking” and “lemon dropping”. J Clin Ethics. 2018;28(1):62–8. 8. Wodowski AJ, Pelt CE, Erikson JA, Anderson MB, Gililland JM.  Peters. Bundle busters. Who is at risk of exceeding the target payment and can they be optimized. Bone Joint J. 2019;101B(7):64–9. 9. Courtney PM, Rozell JC, Melnic CM, Lee GC. Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty. J Arthroplast. 2015;30(Suppl 1):1–4. 10. Memtsoudis SG, Della Valle AG, Besculides MC, Garber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. 3,830,420 hospital discharges in the United States between 1990 and 2004. J Arthroplast. 2009;24(4):518–27. 11. Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score”. J Arthroplast. 2017;32:2325–31. 12. Berger RA.  A comprehensive approach to outpatient total hip arthroplasty. Am J Orthop. 2007;36(9Suppl):4–5. 13. Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ. Outpatient total knee arthroplasty with a minimally invasive approach. J Arthroplast. 2005;20(7 Suppl):33–8. 14. Dorr LD, Thomas DJ, Zhu J, Dastane M, Chao L, Long WT. Outpatient total hip arthroplasty. J Arthroplast. 2010;25:501–6. 15. Stambough JB, Nunley RM, Curry MC, Steger-May L, Clohisy JC. Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplast. 2015;30:521–6. 16. Kingery MT, Cuff GE, Hutzler LH, Popovic J, Davidovitch RI, Bosco JA. Total joint arthroplasty in ambulatory centers: analysis of disqualifying conditions and frequency at which they occur. J Arthroplast. 2018;33:6–9. 17. Boraiah S, Joo L, Inneh IA, Rathod P, Meftah M, Band P, et al. Management of modifiable risk factors prior to primary hip and knee arthroplasty: a readmission risk assessment tool. J Bone Joint Surg Am. 2015;97:1921–8. 18. Shah RP, Karas V, Berger RA. Rapid discharge and outpatient total joint arthroplasty introduce a burden of care to the surgeon. J Arthroplast. 2019;34:1307–11. 19. Manohar A, Cheung K, Wu CL, Stierer TS.  Burden incurred by patients and their caregivers after outpatient surgery: a prospective observational study. Clin Orthop Relat Res. 2014;472:1416–26.

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20. Phillips JLH, Rondon AJ, Vannello C, Filligham YA, Austin MS, Courtney PM. A nurse navigator program is effective in reducing episode of care costs following primary hip and knee arthroplasty. J Arthroplast. 2019;34:1557–62. 21. Kee JR, Edwards PK, Barnes L, Foster SE, Mears SC. After-hours calls in a joint practice. J Arthroplast. 2019;34:1303–6. 22. Zhang J, Dushaj K, Rasquinha VJ, Scuderi GR, Hepinstall M. Monitoring surgical incision site in orthopedic patients using an online physician-patient messaging platform. J Arthroplast. 2019; https://doi.org/10.1016/j.arth.2019.05.003. 23. Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of evidence. Br J Anaesth. 2016;117(S3):iii62–72. 24. Ljungqvist O, SØreide E. Preoperative fasting. Br J Surg. 2003;90:400–6. 25. Berend ME, Berend KR, Lombardi AV.  Advances in pain management. Bone Joint J. 2014;96(11):7–9. 26. Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg. 2011;93(11):1075–84. 27. Sodhi N, Anis HK, Gold PA, Garbarino LJ, Scuderi GR, Cushner FD, Higuera CA, Mont MA. Operative times can predict and are correlated with lengths-f-stay in primary knee arthroplasty: a nationwide database study. J Arthroplast. 2019;34:1328–32. 28. Cleveland Clinic Orthopaedic Arthroplasty Group. The main predictors of length of stay after total knee arthroplasty: patient-related or procedure-related risk factors. J Bone Joint Surg. 2019;101:1093–101. 29. Aynardi M, Post Z, Ong A, Orozco F, Sukin DC. Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case control study. HSS J. 2014;10(3):252–5. 30. Huang A, Ryu JJ, Dervin G. Cost savings of outpatient versus standard inpatient total knee arthroplasty. Can J Surg. 2017;60(1):57–62. 31. Khan S, Johnston L, Faimali M, Gikas P, Briggs TW.  Matching residency numbers to the workforce needs. Curr Rev Musculoskelet Med. 2014;7:168–71. 32. Iorio R, Robb WJ, Healy WL, Berry DJ, Hozack WJ, Kyle RF, Lewallen DG, Trousdale RT, Jiranek WA, Stamos VP, Parsley BS. Orthopedic surgeon workforce and volume assessment for total hip and knee replacement in the United States – preparing for an epidemic. J Arthroplast. 2008;23(2):315–9. 33. Fehring TK, Odum SM, Troyer JL, Iorio R, Kurtz SM, Lau EC. Joint replacement access in 2016. A supply side crisis. J Arthroplast. 2010;25(8):1175–81. 34. Almansoori KA, Clark M.  Increasing trends in orthopedic fellowships are not due to inadequate resident training. Educ Res Int. 2015; https://doi.org/10.1155/2015/191470.

Chapter 2

Understanding Alternative Payment Models Adam J. Schwartz and Kevin Bozic

Introduction The appropriate method of payment to a physician for health care services is a debate that spans history. The oldest written reference to physician remuneration is considered to be the code of Hammurabi written in 2000 BC, which stipulated a payment of ten shekels of silver for specific surgical therapies [1]. The writings of Hippocrates reflect a conflict regarding physician payment, in some cases advocating for the practice of medicine without payment, and in others referring to appropriate payments for specific services. The Hippocratic oath itself refers to the practice of medicine as both an art and a science, implying a delicate balance between an activity done for pure righteousness and one for gainful employment [2]. The predominant method of payment for health care services in the United States has been on a fee-for-service (FFS) basis, meaning that each service is paid for separately and individually [3]. Under this system, fees have either been paid directly by the patient out of pocket or, after private insurance companies began to offer health care coverage in the early 1900s, through a third-party payer. Prior to July 1965, when Congress created Medicare under Title XVIII of the Social Security Act, almost half of patients over the age of 65 were without private health insurance coverage. Since that time, Medicare coverage has expanded on a number of occasions to include groups of patients for which it was not originally intended, including younger patients with amyotrophic lateral sclerosis (ALS), end-stage renal disease, and other chronic conditions, and is now the single largest third-party payer in the United States.

A. J. Schwartz (*) Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA e-mail: [email protected] K. Bozic Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX, USA © Springer Nature Switzerland AG 2020 G. R. Scuderi et al. (eds.), Rapid Recovery in Total Joint Arthroplasty, https://doi.org/10.1007/978-3-030-41223-4_2

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As the US health care system continues to grow more rapidly relative to other segments of the economy, multiple problems associated with the FFS system have been recognized by policy makers [4–6]. Most notably, opponents of FFS models argue that the system is based upon volume and intensity of services rather than value delivered to patients, and as a result, there are no incentives for providers to reduce or eliminate wasteful spending and/or strive for optimal outcomes from the patient’s perspective. Moreover, an FFS system may paradoxically reward poor outcomes as providers caring for adverse events or complications continue to bill for these episodes independently and in addition to the initial treatment. Finally, a system of separate payments for health care encourages the fragmentation of care delivery whereby independent providers have little regard for redundant or additional payments to other providers for services that may or may not be related. The net result of the FFS third-party payer model was the growing recognition that health care costs in this country are spiraling out of control. Given the growing concern over health care costs, the political and economic conditions from 2007 to 2010 have encouraged and, in some respects, facilitated the most extensive health care reform in the United States since the enactment of Medicare [7]. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, with the aims of increasing access to care, reducing the cost of care, and improving the quality of care delivered [8]. Section 3021 of the ACA established the Center for Medicare and Medicaid Services Innovation Center (CMMI), charged with developing and studying alternative payment models (APMs) for physician reimbursement [9, 10]. While many alternatives to FFS exist, the most commonly employed and studied APMs are capitation (whereby a health care organization receives a fixed payment for its covered population, regardless of the volume or cost of care provided) and bundled payments (whereby providers are paid for the entire cycle of a single care episode rather than for each separate individual service). Capitation was popularized in the 1990s with the proliferation of Health Maintenance Organizations (HMOs), and today examples of this model abound with Accountable Care Organizations (ACOs), shared savings plans, and others now tied to specific quality metrics. Critics of the capitation model argue that while capitation may reduce costs at the population level, patients are less interested in population-based outcome measures compared to their own personal health, and providers have little control over the baseline health of the population that they serve. Furthermore, capitation has the potential to incentivize physicians to withhold care [4]. In contrast, proponents of bundled payment systems argue that such a system necessitates providers working together to provide treatment. In addition, as bundled payments are tied to specific outcome measures, the system holds the group of providers for any treatment episode accountable for delivering high-value care. Proponents also argue that the successful implementation of a bundled payment program demands a concrete understanding of the costs involved in delivering care, which will encourage the development of improved accounting methodology by health care institutions. Bundled payments are not a new concept. The first use of a bundled payment was the creation of a comprehensive global fee for cardiovascular surgery at the

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Texas Heart Institute in 1984, a program that succeeded in reducing costs, improving access to care, and maintaining preprogram patient outcomes [11]. Around the same time, Medicare, recognizing the need to move away from high variability in “usual and customary charges” for inpatient services, created the inpatient prospective payment system (IPPS) and began basing hospital payments for certain conditions on specific diagnosis-related groups (DRGs). While some argue that newer bundled payment models are similar to the currently employed DRG system, there are a number of important differences: (1) DRGs do not include payment for the full cycle of care (physician, postacute care), (2) DRGs are not tied to outcome measures, and (3) many important inpatient services are not included in the DRG payment, such as patient education and care coordination [4]. In a further step toward contemporary bundled payments, in 2009, the Centers for Medicare and Medicaid Services (CMS) (changed from the Health Care Financing Administration to CMS on June 14, 2001), began a three-year pilot program called the Medicare Acute Care Episode (ACE) Demonstration [12]. Closer in concept to a contemporary bundled payment model, the essential difference between ACE and DRG payments was the inclusion of physician payments, along with hospital payments, for the entire inpatient hospital episode. Currently, CMS provides universal health care coverage to the growing population of patients over age 65 and is the single largest purchaser of health care services in the United States. With the passage of the ACA and the launch of the CMMI, recent years have witnessed heightened interest in bundled payment models as an alternative to an FFS payment system. Currently, CMMI lists over 40 alternative payment models being implemented for various disease groups, patient populations, and care episodes. Given the growing body of evidence that demonstrates effective cost reduction and quality improvement associated with many of these programs, future years are likely to see an expansion of these programs, regardless of the political climate. In this chapter, we explore the APMs that are most applicable to the practice of TJA, offer suggestions for the successful implementation of these payment models, and review the current evidence gleaned from institutions that have participated in each of these models.

 nderstanding the Common Alternative Payment U Models (APMs)  undled Payment Models: Bundled Payments for Care B Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) Porter argues that the five conditions for a bundled payment model to maximize value for a patient include the following: (1) the payment should cover the overall care required to treat a condition, (2) payment is contingent on delivering good

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outcomes, (3) payment is adjusted for risk, (4) payment provides a fair profit for effective and efficient care, and (5) providers are not responsible for unrelated care or catastrophic cases [4]. These criteria provide a conceptual framework from which to evaluate the merits of any individual bundled payment system and a useful background for an examination of each CMMIC alternative model. As we shall see, while each model may incorporate individual elements of this list, a comprehensive model that maximizes value has yet to be deployed. While a number of alternative payment models have come and gone in recent years, it is useful to examine the narrative of each to provide context for the evaluation of new models as they are proposed. Originally a 3-year pilot program authorized through the ACA, the Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMMI in 2011; it began accepting applications late during that year and the following year; and the first cohort of awardees in Model 1 began in April of 2013 [13]. Forty-eight different episodes of care, ranging from diabetes care to pacemaker placement, were eligible for participation in BPCI. The eligible episodes defined by the BPCI program pertaining to lower extremity arthroplasty were major joint replacement of the lower extremity (DRG 469 or 470), bilateral simultaneous joint replacement of the lower extremity (DRG 461 or 462), revision of the hip or knee (DRG 466, 467, or 468), and other knee procedures (DRG 485, 486, 487, 488, or 489). While rare instances of participation for many of these episodes have been described, the vast majority of applications of this program were related to uncomplicated primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (DRG 469 or 470). Participation in the BPCI program was voluntary, and providers were able to select from four program reimbursement models. Models 1, 2, and 3 were retrospective payment models (payments from CMS occurred after care was delivered), while Model 4 was prospective (payment from CMS was given prior to care given). Model 1 separated physician payments from hospital payments for the global period, while Models 2 and 3 stipulated a retrospective bundled payment where actual expenditures were reconciled against a target price for an episode of care. Whereas both Models 2 and 3 were triggered by an acute care hospitalization, Model 2 included inpatient hospital stay and a 90-day postoperative period. Model 3 only included 90-day postoperative period, beginning with an initiation of postacute care services through a skilled nursing facility (SNF), inpatient rehabilitation facility, long-term care hospital, or home health agency. Under this system, the same payments were made as would be done under an FFS system; however on a quarterly basis, the total expenditures for the episode were compared to the predetermined bundled payment amount (also known as the target price). If the episode cost (reflected by the FFS reimbursement) exceeded the target price, CMS required additional payments; however if costs were less than the target price, Medicare issued a payment to cover the difference. BPCI was implemented in two separate phases: phase 1 (known as the “preparation” period) and phase 2 (known as the “risk-bearing” period). The entity that was ultimately responsible for bearing the financial risk is known as the BPCI Episode Initiator and could be an acute care hospital, physician group practice, home health

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agency, skilled nursing facility, inpatient rehabilitation facility, or a long-term care hospital. In the preparation period, CMS provided the episode initiator with its own historical Medicare expenses to prepare for transition to a bundled reimbursement. Following this data collection period, the CMS, in conjunction with the initiating organization, set quality measures, along with target prices aimed at improvement in costs for a given episode of care. A major contention regarding this method was the tendency for high-cost outlier organizations to participate, given that bonuses were largely based on improvements over past performances, as well as the ability for institutions to choose their own quality measures [5]. For higher performing, already lower cost providers, participation in BPCI was relatively unattractive, given the minimal opportunity for cost savings and bonus payments. Other concerns regarding BPCI included the possibility of withholding care to certain high-risk groups (so-called cherry picking) [14], transfer of high-risk patients to tertiary care centers (so-called lemon dropping) [9], and the inclusion of hip fractures, associated with higher risks and costs, under the definition of the BPCI episode of care [15, 16]. Given these concerns, and building on the previous success of BPCI, in April 2016, the CMS introduced a separate bundled payment model called the Comprehensive Care for Joint Replacement (CJR) [17]. While related, there exist a number of major differences between BPCI and CJR: (1) participation in CJR is mandatory (as of the time of preparation of this chapter, over 400 hospitals in 67 different metropolitan areas are participating in CJR); (2) the duration of participation is 5 years (CJR is currently scheduled to run through December 31, 2020); (3) the model only applies to total hip and total knee replacement (DRG 469 and 470, with a separate hip fracture pathway); (4) the initiator can only be an acute care hospital; (5) target prices are determined from both provider data and regional information; and (6) the discount to CMS is based upon patient quality metrics [9, 17]. These quality metrics used for the calculation of the CMS discount represent a composite score of risk-adjusted complication rates and postdischarge Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaires.

MACRA and QPP In parallel with CMMI’s development and evaluation of alternative payment models, CMS has spent considerable effort toward containing US health care expenditures and preserving a balanced budget [18]. With the 1997 Balanced Budget Act, Congress passed an amendment to the Social Security Act creating the sustainable growth rate (SGR) formula [19]. The fundamental concept of the SGR effectively tied the growth of US health care expenses to the US gross domestic product. On an annual basis, the formula required an adjustment of FFS payments to maintain budget neutrality. It was not until the first negative adjustment took place in 2002 that physicians took note of this annual ritual [20]. From that point forward, concerned physicians repeatedly awaited Congress’ decision as to whether or not a temporary fix would be provided to avoid reductions in reimbursements.

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The Medicare Access and CHIP Reauthorization Act of 2015 effectively repealed the SGR and in its place established the Quality Payment Program (QPP), a new system for maintaining budget neutrality, allowing providers to participate through one of two options: the Merit-Based Incentive Payment System (MIPS) and advanced alternative payment methods (APMSs) [18]. QPP, which currently applies to all physicians caring for more than 200 Medicare beneficiaries, billing more than $90,000 a year in charges, and not new to the Medicare system, aims to achieve budget neutrality by providing bonus payments for high-quality care while reducing payments to clinicians who fail to meet value-based standards. It is important to note that this system only achieves budget neutrality if the payment increases to high-performing providers are offset by losses to other providers. While losses in this system are typically fixed, gains will be combined with a “budget neutrality factor” that accounts for the expected inequality between penalized vs. rewarded providers [21]. While a full discussion of MIPS is beyond the scope of this chapter, it is critical to recognize that unless a provider who is eligible for QPP participates in an advanced APM, they will automatically be defaulted to MIPS. The advanced APM track of the QPP presents providers with the opportunity to earn a 5-percent lump sum incentive payment (on top of Medicare fee schedules) for up to 6 years (2019–2024) [21]. The availability of advanced APMs to current TJA surgeons is limited. To qualify as an advanced APM, the APM must meet three criteria: (1) it requires a minimum of 75% of participants to use certified electronic health record (EHR) technology, (2) it provides payment for covered professional services based on quality measures comparable to those used in MIPS quality performance category, and (3) it either is a medical home model expanded under CMS innovation authority or requires participants to bear a significant financial risk. A minimum of 50% of Medicare Part B payments or at least 35% of Medicare patients must come from an advanced APM. Most advanced APM entities are Accountable Care Organizations [22].

Private Insurance and Employer-Provider Contracts The most common bundled payment programs are currently being deployed by CMS for application to Medicare beneficiaries. However, the bundled payment model may be applied by any third-party payer, including private insurance companies or large corporations seeking to reduce health care expenses [23]. In 2010, the Agency for Healthcare Research and Quality (AHRQ) awarded a $2.9-million research grant to the Integrated Healthcare Association (IHA), a leadership group, and the Rand Corporation, an independent program evaluator, to create an orthopedic surgery bundled episode model for patients under age 65 in the state of California [24]. The program, called the IHA Bundled Episode and Gainsharing Demonstration, met with similar challenges faced by prior bundled payment initiatives. Despite beginning the program with eight participating hospitals and six health plans, only three health plans ultimately offered contracts and only two hospitals signed these

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contracts. In their review of the program, Ridgely and colleagues cite numerous roadblocks to implementing the program, including difficulty in defining the care episode, provider propensity toward offering care to lower risk patients, delays in regulatory mechanisms, and deficiencies in appropriate structures for claims. The authors encourage continued efforts toward the implementation of the bundled payment model in the private sector through simple bundle definitions, the implementation of appropriate use criteria, and developing risk management methods acceptable to all parties. In addition to bundled payment models initiated by government and commercial insurers, large self-insured employers are more frequently seeking bundled contracts with provider groups when their third-party administrators do not have interest in pursuing these alternative payment structures [4]. The potential advantages of this approach to employers include reductions in health care expenditures, competitive benefit offerings to their employees, and the improved ability to strictly define offered benefits [25]. Two of the more notable attempts by employers in this domain have come from the Pacific Business Group on Health (PBGH), which represents multiple companies, including Lowe’s, Walmart, and others), and the Boeing Corporation. In some of these arrangements, predetermined self-insured bundled payments are made to providers in exchange for concierge-like services, including next-day appointments, expanded shared-decision-making tools, and decreased or completely eliminated co-pays. In January 2014, PBGH formed the Employers Center of Excellence Network (ECEN), which used prospective, DRG-based, and episode-based bundled rates to provide care for employees, including coverage for medical and travel expenses during the defined bundle period. Within 2 years, over 1400 TJA procedures had been performed under the ECEN program, which was ultimately expanded to include spine care and other procedures. Compared to patients undergoing TJA under the FFS model, patients under the ECEN model had lower discharge to skilled nursing facilities (9% vs 0%), reduced 30-day readmission rates (5.9% vs 0.4%), and revision procedures (1.1% vs. 0%). Fifteen percent of patients were deemed too high risk for the procedure under the ECEN program, although 8% of these patients opted to continue with surgical intervention under their conventional benefit package [25].

Cash-Pay Practice A less commonly employed alternative payment model is the cash-pay TJA practice. Under this model, the third-party payer is removed from the equation entirely and the patient pays the physician’s professional fees directly out of pocket. Coverage of hospital fees and postacute care charges under this system is variable and depends largely upon prenegotiated rate and the financial structure of the care delivery team. Under some arrangements, while the physician’s professional fees are paid directly, the acute-care episode remains covered by negotiated private insurance rates. In other settings, the patient’s out-of-pocket payment covers the entire episode of care,

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including hospital and implant costs. It is important to note that under this model, the surgeon cannot continue to bill CMS for care provided to Medicare beneficiaries as it is illegal for a provider to charge a separate fee in addition to allowed Part B payments. Instead, the surgeon must “opt-out” of Medicare, which does not mean that they cannot continue to care for Medicare patients, only that the provider will not submit Part B claims to Medicare for the care provided. As of January 1, 1998, an amendment to the Social Security Act permits surgeons and their Medicare patients to enter into private written financial contracts. Each cash-­pay practice, in conjunction with a legal team, typically generates its own version of this contract to permit direct billing for services. Given the increasing prevalence of high-deductible insurance plans and the growing administrative burden associated with third-party payment, recent years have witnessed an increasing popularity of cash-pay and medical tourism [26]. Advocates of a cash-pay practice argue that this approach encourages the maximization of value as the dual role of the patient as a payer encourages a free-market approach to health care purchasing. In practice, it is not uncommon for patients to report highquality, perhaps even luxurious, care under this model [26]. Additionally, from the provider perspective, these arrangements typically offer reduced administrative burden, increased reimbursement for often significantly lower surgical volumes, and reduced physician burnout [27]. Critics of an all-cash TJA practice argue that while theoretically all-cash surgeons could provide charity care, only the most wealthy patients have access to these high-performing providers, and such a system does not address the health care system as a whole. Dr. Alan Morris, in a roundtable discussion, pointed to the 1999 American Academy of Orthopaedic Surgeons (AAOS) Public Relations Task Force survey, which gave orthopedic surgeons low scores on caring and compassion. He believes that a cash-only practice is counter to recent AAOS efforts to improve the perception of orthopedic surgeons [28]. While some point to the dental industry as an example of an effective implementation of cashbased payment, Morris argues that hip and knee arthritis are completely debilitating while foregoing necessary dental work might cause a patient to simply “chew on the other side of [their] mouth” [27, 29]. As stated at the outset of this chapter, the ethics of physician remuneration has been argued across countless generations; it is likely that despite these criticisms, the cash-pay TJA practice will remain a viable, albeit relatively uncommon, alternative payment model in the future. For uninsured patients who cannot afford surgery in the United States or private corporations looking to lower their medical expenses for employees, medical tourism offers a potentially lower cost alternative. It is currently estimated that 14–16 million patients annually will leave the united States for health care abroad [30]. The most frequently visited countries in a recent series were Costa Rica, India, Malaysia, and Mexico, where the cost of TJA is estimated to be less than one third compared to US prices [31]. In recognition of this growing trend, the American Medical Association published an ethical guideline for physicians who care for patients expressing interest in medical tourism [32]. In addition to showing ­compassion and understanding, the guideline recommends that providers point out the potential risks and the importance of postoperative care. It is critical for patients

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to understand if and where follow-up care will be available; conversely, it is also important for providers to respond compassionately when a medical tourist returns and requests for nonemergent follow-up care. If a provider is unable or unwilling to provide care, it is considered ethical to refer the patient for appropriate treatment elsewhere. While there are no current reports of higher complication rates among TJA patients treated abroad, other specialties have reported a substantial number of cases treated for postoperative complications following surgery done in other countries [33]. The Centers for Disease Control and Prevention (CDC) provides robust recommendations for United States citizens interested in medical tourism [34].

Keys to the Successful Implementation of APMs A plethora of continuing medical education (CME) courses, webinars, industry- and society-sponsored programs, and published articles are available to aid the clinician and their practices and health system partners in the implementation of a variety of alternative payment models (Table 2.1). Bosco and colleagues argue that the major

Table 2.1  Various approaches to the successful implementation of bundled payments in total joint arthroplasty Author Bozic et. al. [44]

Strategy framework 1. Identify clinical condition

Comments Cases that present at the average rate of one per business day (approximately 200–250 cases per year) are ideal for implementation of bundled payment

 Volume  Variable cost and quality  Relative case homogeneity  Robust measurement tools Champions should have appropriate authority and 2. Identify clinical and vision administrative champions 3. Define the episode Inclusion/exclusion criteria are critical. Payer type, transfer status, age, indication for surgery are all important elements to define the target population  Starting point or trigger  Duration of the episode  Inclusion/exclusion criteria Appropriate quality and safety thresholds are 4. Define performance important to offset the potential for withholding care metrics and the gainsharing model (continued)

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Table 2.1 (continued) Author

Strategy framework Comments 5. Map the episode of care Process mapping and TDABC may help to highlight and costs bottlenecks in the process, and opportunities for greater efficiencies 6. Identify opportunities Evidence-based and consensus-based (expert opinion) for improvement help narrow the gap between institutional and best practices Employment of a management system that allows for 7. Redesign care to nimble response to process improvement ideas from improve quality and stakeholders reduce cost 8. Price and market the Identifying outliers and developing a pricing strategy episode of care may mitigate the downside risk of fixed bundled prices 9. Evaluate results and A multidisciplinary committee should meet regularly to iterate monitor implementation and make adjustments when necessary Bosco et. 1. Modification of patient The authors argue that it is rational and ethical to al. [35] risk withhold TJA from patients with modifiable risk factors 2. Adoption of evidence-­ VTE and blood management are examples of care based pathways pathways that may be optimized to reduce provider variation 3. Establishment of a data Data management needs to occur in real time so that care teams are able to quickly respond to concerning collection and trends in outcomes dissemination infrastructure 4. Control of postdischarge A large portion of cost savings may occur in the care and costs postdischarge phase. Risk assessment is useful to reduce readmissions 5. Maximization and Providers need to be aware of three CMS quality demonstration of quality metrics (standardized complication rate, HCAHPS survey, and PROs). Gainsharing depends upon appropriate 6. Identification and communication between all stakeholders (surgeons, alignment of anesthesiologists, PT, nurses, social workers, among stakeholders others Suggestions for each period Suggestions for each category are organized by the Van target toward which the process improvement is aimed. Citters et. organized as follows: The authors identify 132 total suggestions to develop a al. [43] streamlined clinical pathway for TJA  Providing safe, effective, efficient, and patientand family-centered care  Reducing waste  Avoiding communication pitfalls 17 suggestions 1. Processes that apply across the continuum of care

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Table 2.1 (continued) Author

Strategy framework 2. Period 1: preoperative surgical office visit 3. Period 2: preoperative preparation and planning 4. Period 3a: inpatient experience – preparation, operation, and PACU 5. Period 3b: inpatient experience – inpatient stay and discharge process 6. Period 4: postdischarge rehabilitation and follow-up care

Comments 24 suggestions 22 suggestions

22 suggestions

27 suggestions

20 suggestions

TDABC time-dependent activity-based costing, VTE venous thromboembolism, TJA total joint arthroplasty, HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems, PRO patient-reported outcome, PT physical therapy, CMS Centers for Medicare and Medicaid Services, PACU postanesthesia care unit

elements to the successful implementation of a bundled payment model include seven key principles: (1) modification of patient risks, (2) adoption of evidence-­ based clinical pathways, (3) establishment of a data collection and dissemination infrastructure, (4) control of postdischarge care and costs, (5) maximization and demonstration of quality, and (6) identification and alignment of stakeholders [35]. The authors argue that insistence upon addressing potentially modifiable risk factors prior to TJA, such as smoking, obesity, and poorly controlled diabetes, is appropriate and ethical [36]. Venous thromboembolism (VTE) [37], blood management [38, 39], and pain management [40, 41] pathways represent a sampling of evidence-based clinical guidelines that should be employed and standardized, particularly for lower volume providers. Real-time data tracking of VTE rates, surgical site infections, readmissions, and acute and postacute care costs are critical to understanding the cost-quality equation and the effect on a bundled payment. In addition to understanding the factors that drive in-hospital costs, a robust mechanism to track the usage of postacute care facilities, readmissions, and complications is imperative. An important component to managing postacute utilization is the development and usage of predictive risk assessment tools. Currently, three metrics are combined into a composite score by the CMS to determine the quality of care delivered under a bundled model: hospital riskadjusted complication rate, data from the HCAHPS survey, and patient-reported outcomes [35]. It is critical for institutions and providers in a bundled model to

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monitor performance among these metrics. Ensuring that all team members involved in delivering care under a bundled model are aligned toward a common goal is critical to success. Bosco and colleagues argue that gainsharing (providers sharing in the cost savings achieved in the delivery of care) can be an effective method of aligning provider interests and efforts. CMS has approved and encouraged gainsharing as long as (1) the agreement is discussed with the patient, (2) payments are for services actually provided in the bundle, (3) payments are tied to quality, and (4) payments are capped at 50% above standard Medicare reimbursement rates [35, 42]. Van Citters and colleagues performed a mixed-method analysis to design and evaluate a 14-month care pathway that includes a presurgical office visit through the entire care cycle 1 year postoperatively [43]. The pathway includes 40 process improvements, 37 waste-reduction techniques, and 55 team-building communication improvement methods. While the authors admit that this pathway represents a proposal, and no attempt was made in the study to implement the pathway or analyze effects on costs or care quality, many of the recommendations from the study are likely to be of use to providers and institutions implementing an alternative payment model, and the reader is encouraged to examine the study’s findings. In their review article, Bozic and Ward detail their experience with an alternative payment structure at their institution [44]. The authors outline nine sequential strategies for the successful implementation of a bundled payment system, along with critical implementation challenges. The competing incentives between FFS and bundled payment structures presents one of the more salient challenges for an institution transitioning to an alternative payment model. Similarly, the added work and data manipulation for administrative staff may result in errors in outcome assessment or inappropriate patient selection. The authors point out that initially, most institutions will experience significant strain during the transition period but that these challenges may be mitigated by early implementation of policy and infrastructure changes conducive to a bundled payment structure, even if only a minority of cases fall into this category.

Current Evidence Existing evidence on the impact of bundled payments in TJA generally points to reductions in cost, and improvements or preservation of quality under bundled payment systems for THA and TKA. Due to its longer duration in practice, more data are currently available regarding the BPCI model than for CJR. Dummit and colleagues performed a difference-in-difference analysis using Medicare claims data from March 2011 to December 2015 and found that under the BPCI initiative, Medicare payments declined in greater magnitude compared to non-BPCI participating hospitals, with no difference in 30- and 90-day readmissions, 30- and 90-day emergency department visits, or 30- or 90-day postdischarge mortality [45]. Similarly, in an analysis of a single large tertiary care academic urban medical cen-

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ter, Dundon and coauthors compared 721 Medicare TJAs in year 1 of BPCI Model 2 to 785 Medicare TJAs performed in year 3 [46]. The authors found that in addition to a 20% reduction in 90-day costs per episode of care, the average length of stay was reduced from 3.58 to 2.96, discharge to postacute care inpatient facilities decreased from 44% to 28%, and all-cause readmissions within 60 days declined from 11% to 6%. While extensive literature supports the contention that quality can be maintained, or even improved as costs are reduced under the BPCI model [47–52], readmissions can be disastrous to the financially responsible institution. Clair and colleagues reviewed the experience of a single urban tertiary academic orthopedic hospital caring for over 600 patients under the BPCI model [53]. The authors found that within 90  days, 10% of patients experienced a readmission, ­approximately half of which were due to surgical complications. The authors present staggering mean readmission costs, ranging from a low of $4790 to well over $100,000. Additionally, the costs of creating the infrastructure necessary to thrive under BPCI can be significant (one institution reported over $200,000 of start-up expenses), favoring larger institutions with more financial resources [54]. In an analysis of CJR, Barnett and colleagues conducted a difference-in-­difference analysis using Medicare claims data from 2015 through 2017 and found that during the first 2  years of bundled payments, there were significant cost reductions (largely through lower postacute care utilization) and no change in complications or percentage of high-risk cases [55]. In a similar analysis, Finkelstein and coauthors compared 67 metropolitan statistical areas (MSAs) with implemented CJR programs to 121 controls and found that lower extremity joint replacements performed in the CJR MSA group had an almost 3% lower discharge to institutional postacute care, but had similar costs [56]. Gray studied the implementation of the CJR model at a single academic medical center and demonstrated a reduction in length of stay (from 3.6 to 2.1 days), readmissions (15–6%), complications (2.3–1.9%), and cost (almost 20%) [56]. In contrast to these findings, Ryan and colleagues compared 1564 TKA procedures performed at a CJR institution to 744 TKAs performed at an FFS hospital and found no difference in patient demographics or 90-day emergency department visits of readmissions [57]. The authors did, however, demonstrate a reduction in cost, again, mainly through discharge disposition and length of stay. Overall, the surgical episode-based bundles have largely improved care coordination, reduced cost, and maintained the high quality historically associated with TJA procedures. On the other hand, there is currently no evidence that utilization rates of surgical care for the diagnosis of osteoarthritis have declined with the implementation of bundled payment for TJA. In fact, as surgeons become more efficient under a bundled model, it is possible that unchecked, surgical volumes may continue to rise in the coming years. Additionally, it is estimated that approximately 30% of current TKA procedures are medically unnecessary [58]. It is likely that only through bundling at the condition level for a given diagnosis (e.g., hip or knee arthritis) will appropriate and meaningful reductions in utilization rates occur [59]. Bundling the care episode for osteoarthritis from the time of initial evaluation has been shown to effect a 25% reduction in surgical utilization and an over 20% improvement in functional status among all patients included in the condition-based care bundle [60].

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Conclusion The United States currently spends 17.8% of its gross domestic product on health care, approximately twice as much as other high-income countries, but ranks among the lowest in many quality metrics [61]. Total joint arthroplasty (TJA) represents the single largest inpatient line-item expense for Medicare beneficiaries, and utilization rates for total hip and knee arthroplasty (THA and TKA) are expected to rise in the coming decades [17]. Thus, it is no surprise that TJA represents a prime target for payers and policy makers seeking to lessen the economic burden of rising health care costs in this country. Critics of the conventional FFS model argue that this payment method has resulted in a health care environment defined by fragmented, often redundant, and wasteful care, where volume and intensity of services rather than value delivered to patients is rewarded. The ACA of 2010 brought heightened interest in value-based health care delivery and payment models, characterized by reimbursement methods that are tied to various quality metrics. While various other alternative payment models exist, the CMMI and other stakeholders have largely focused on bundled payments as the most appropriate in the context of lower extremity total joint replacement. Despite recent and future changes in the US political environment, bundled payment models are likely to persist, requiring a thorough understanding of the merits and shortcomings of each particular model, along with an appreciation for the key factors leading to successful implementation.

References 1. Tom W. A brief history of physician remuneration. Univ West Ont Med J. 2008;78(2):38. 2. Askitopoulou H, Vgontzas AN. The relevance of the Hippocratic oath to the ethical and moral values of contemporary medicine. Part I: the Hippocratic oath from antiquity to modern times. Eur Spine J. 2018;27(7):1481. 3. Wynne B. For medicare’s new approach to physician payment, big questions remain. Health Aff (Millwood). 2016;35(9):1643. 4. Porter ME, Kaplan RS. How to pay for health care. Harv Bus Rev. 2016;94(7–8):88–100. 5. McLawhorn AS, Buller LT.  Bundled payments in total joint replacement: keeping our care affordable and high in quality. Curr Rev Musculoskelet Med. 2017;10(3):370. 6. James BaP, G. The case for capitation. Harvard Business Review. 2016. 7. Chambers MC, El-Othmani MM, Saleh KJ. Health care reform: impact on total joint replacement. Orthop Clin North Am. 2016;47(4):645. 8. Gwam CU, Mohamed NS, Etcheson JI, Davila Castrodad IM, Mistry JB, Recai TM, Delanois RE. Changes in total knee arthroplasty utilization since the implementation of ACA: an analysis of patient-hospital demographics, costs, and charges. J Knee Surg. 2019;25:25. 9. Siddiqi A, White PB, Mistry JB, Gwam CU, Nace J, Mont MA, Delanois RE. Effect of bundled payments and health care reform as alternative payment models in total joint arthroplasty: a clinical review. J Arthroplast. 2017;32(8):2590–7. 10. Lee KJ, Min BW, Bae KC, Cho CH, Kwon DH. Efficacy of multimodal pain control protocol in the setting of total hip arthroplasty. Clin Orthop Surg. 2009;1(3):155.

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11. Froimson MI, Rana A, White RE Jr, Marshall A, Schutzer SF, Healy WL, Naas P, Daubert G, Iorio R, Parsley B. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplast. 2013;28(8 Suppl):157. 12. Busch CA, Whitehouse MR, Shore BJ, MacDonald SJ, McCalden RW, Bourne RB. The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. Clin Orthop Relat Res. 2010;468(8):2152. 13. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplast. 2007;22(6 Suppl 2):33. 14. Courtney PM, Huddleston JI, Iorio R, Markel DC. Socioeconomic risk adjustment models for reimbursement are necessary in primary total joint arthroplasty. J Arthroplast. 2017;32(1):1. 15. Voskuijl T, Neuhaus V, Kinaci A, Vrahas M, Ring D. In-hospital outcomes after hemiarthroplasty versus total hip arthroplasty for isolated femoral neck fractures. Arch Bone Joint Surg. 2014;2(3):151. 16. Le Manach Y, Collins G, Bhandari M, Bessissow A, Boddaert J, Khiami F, Chaudhry H, De Beer J, Riou B, Landais P, Winemaker M, Boudemaghe T, Devereaux PJ. Outcomes after hip fracture surgery compared with elective total hip replacement. JAMA. 2015;314(11):1159. 17. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014;96(8):624. 18. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/ nationalhealthexpenddata/nhe-fact-sheet.html. In: CMS national health expenditure data sheet. 19. House of Representatives. H.R. 2015 Balanced Budget Act of 1997. 1997. 20. Hirsch JA, Rosenkrantz AB, Ansari SA, Manchikanti L, Nicola GN.  MACRA 2.0: are you ready for MIPS? J Neurointerv Surg. 2017;9(7):714. 21. Saleh KJ, Sayeed Z, Anoushiravani AA, Darwiche HF, Little B, Frush TJ, El-Othmani MM. Reimbursement based on value in knee surgery: what you need to know about the medicare access and children’s health insurance program reauthorization act of 2015. J Knee Surg. 2017;30(1):12. 22. Martin DP, Diehr P, Cheadle A, Madden CW, Patrick DL, Skillman SM.  Health care utilization for the “newly insured”: results from the Washington basic health plan. Inquiry. 1997;34(2):129. 23. LaPointe J. Private sector to drive bundled payments after CMS cancellations. Revcycle intelligence. 2017. 24. Ridgely MS, de Vries D, Bozic KJ, Hussey PS. Bundled payment fails to gain a foothold in California: the experience of the IHA bundled payment demonstration. Health Aff (Millwood). 2014;33(8):1345. 25. Slotkin JR, Ross OA, Newman ED, Comrey JL, Watson V, Lee RV, Brosious MM, Gerrity G, Davis SM, Paul J, Miller EL, Feinberg DT, Toms SA. Episode-based payment and direct employer purchasing of healthcare services: recent bundled payment innovations and the Geisinger health system experience. Neurosurgery. 2017;80(4s):S50. 26. Edwards H. What happens when doctors only take cash. Time. 2017. 27. Pollock M, Somerville L, Firth A, Lanting B.  Outpatient total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty: a systematic review of the literature. JBJS Rev. 2016;4(12). 28. Why public doesn’t use orthopaedists: surveys disclose views of physicians, patients, consumers. In. http://www2.aaos.org/bulletin/apr99/fline3.htm. 1999. 29. Jackson D.  Third-party free and cash-only practices: changing times call for extreme measures. Orthopaedics Today. 2008. 30. Dalen JE, Alpert JS. Medical tourists: incoming and outgoing. Am J Med. 2019;132(1):9. 31. The pros and cons of medical tourism. In. http://www.kneereplacementcosts.com/medicaltourism.html.

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32. Your patient wants to be a medical tourist: 6 things you should do. In. https://www.ama-assn. org/delivering-care/ethics/your-patient-wants-be-medical-tourist-6-things-you-should-do. 33. Ross KM, Moscoso AV, Bayer LR, Rosselli-Risal L, Orgill DP.  Plastic surgery complications from medical tourism treated in a U.S. Academic Medical Center. Plast Reconstr Surg. 2018;141(4):517e. 34. Medical Tourism. In. https://www.cdc.gov/features/medicaltourism/index.html. 35. Bosco JA, Harty JH, Iorio R. Bundled payment arrangements: keys to success. J Am Acad Orthop Surg. 2018;26(23):817. 36. Bronson WH, Fewer M, Godlewski K, Slover JD, Caplan A, Iorio R, Bosco J. The ethics of patient risk modification prior to elective joint replacement surgery. J Bone Joint Surg Am. 2014;96(13):e113. 37. Odeh K, Doran J, Yu S, Bolz N, Bosco J, Iorio R. Risk-stratified venous thromboembolism prophylaxis after total joint arthroplasty: aspirin and sequential pneumatic compression devices vs aggressive chemoprophylaxis. J Arthroplast. 2016;31(9 Suppl):78. 38. Demos HA, Lin ZX, Barfield WR, Wilson SH, Robertson DC, Pellegrini VD Jr. Process improvement project using tranexamic acid is cost-effective in reducing blood loss and transfusions after total hip and total knee arthroplasty. J Arthroplast. 2017;32(8):2375. 39. Slover J, Bosco J. Cost analysis of use of tranexamic acid to prevent major bleeding complications in hip and knee arthroplasty surgery. Am J Orthop (Belle Mead NJ). 2014;43(10):E217. 40. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, Seamans DP.  The Chitranjan Ranawat Award: periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: a randomized clinical trial. Clin Orthop Relat Res. 2015;473(1):45. 41. Elmallah RK, Chughtai M, Khlopas A, Newman JM, Stearns KL, Roche M, Kelly MA, Harwin SF, Mont MA. Pain control in total knee arthroplasty. J Knee Surg. 2018;31(6):504. 42. Medicare’s bundled payment initiatives: considerations for providers www.ashe.org/ guidesreports/2016.01.19. 43. Van Citters AD, Fahlman C, Goldmann DA, Lieberman JR, Koenig KM, DiGioia AM 3rd, O’Donnell B, Martin J, Federico FA, Bankowitz RA, Nelson EC, Bozic KJ.  Developing a pathway for high-value, patient-centered total joint arthroplasty. Clin Orthop Relat Res. 2014;472(5):1619. 44. Bozic KJ, Ward L. A strategy for successful implementation of bundled payments in orthopaedic surgery. JBJS Rev. 2014;2(10):e2. 45. Dummit LA, Kahvecioglu D, Marrufo G, Rajkumar R, Marshall J, Tan E, Press MJ, Flood S, Muldoon LD, Gu Q, Hassol A, Bott DM, Bassano A, Conway PH. Association between hospital participation in a medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodes. JAMA. 2016;316(12):1267. 46. Dundon JM, Bosco J, Slover J, Yu S, Sayeed Y, Iorio R. Improvement in total joint replacement quality metrics: year one versus year three of the bundled payments for care improvement initiative. J Bone Joint Surg Am. 1949;98(23):2016. 47. Edwards PK, Hadden KB, Connelly JO, Barnes CL. Effect of total joint arthroplasty surgical day of the week on length of stay and readmissions: a clinical pathway approach. J Arthroplast. 2016;31(12):2726. 48. Iorio R, Clair AJ, Inneh IA, Slover JD, Bosco JA, Zuckerman JD. Early results of medicare’s bundled payment initiative for a 90-day total joint arthroplasty episode of care. J Arthroplast. 2016;31(2):343. 49. Kee JR, Edwards PK, Barnes CL.  Effect of risk acceptance for bundled care payments on clinical outcomes in a high-volume total joint arthroplasty practice after implementation of a standardized clinical pathway. J Arthroplast. 2017;32(8):2332. 50. Navathe AS, Troxel AB, Liao JM, Nan N, Zhu J, Zhong W, Emanuel EJ. Cost of joint replacement using bundled payment models. JAMA Intern Med. 2017;177(2):214. 51. Preston JS, Caccavale D, Smith A, Stull LE, Harwood DA, Kayiaros S. Bundled payments for care improvement in the private sector: a win for everyone. J Arthroplast. 2018;33(8):2362.

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52. Rondon AJ, Phillips JLH, Fillingham YA, Gorica Z, Austin MS, Courtney PM. Bundled payments are effective in reducing costs following bilateral total joint arthroplasty. J Arthroplast. 2019;28:28. 53. Clair AJ, Evangelista PJ, Lajam CM, Slover JD, Bosco JA, Iorio R. Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative. J Arthroplast. 1862;31(9):2016. 54. Althausen PL, Mead L. Bundled payments for care improvement: lessons learned in the first year. J Orthop Trauma. 2016;30(Suppl 5):S50. 55. Barnett ML, Wilcock A, McWilliams JM, Epstein AM, Joynt Maddox KE, Orav EJ, Grabowski DC, Mehrotra A. Two-year evaluation of mandatory bundled payments for joint replacement. N Engl J Med. 2019;380(3):252. 56. Finkelstein A, Ji Y, Mahoney N, Skinner J. Mandatory medicare bundled payment program for lower extremity joint replacement and discharge to institutional postacute care: interim analysis of the first year of a 5-year randomized trial. JAMA. 2018;320(9):892. 57. Ryan SP, Howell CB, Wellman SS, Attarian DE, Bolognesi MP, Jiranek WA, Aronson S, Seyler TM.  Preoperative optimization checklists within the comprehensive care for joint replacement bundle have not decreased hospital returns for total knee arthroplasty. J Arthroplast. 2018;17:17. 58. Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol (Hoboken, NJ). 2014;66(8):2134. 59. O’Donnell J SR, Japinga M, Higgins A, Mather C, Jiranek B, McClellan M, Bozic K. Expanding payment reforms to better incentivize chronic care for degenerative joint disease. Health Aff (Millwood). 2018. 60. Andrawis J MM, Bozic K. Bundled payments are moving upstream. NEJM Catalyst. 2019;5(1). 61. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-­ income countries. JAMA. 2018;319(10):1024.

Chapter 3

Insurance Contracting for Outpatient Arthroplasty Programs Adam E. Roy, Owen R. O’Neill, and Richard Iorio

Introduction Total joint arthroplasty (TJA) is among the most common and most expensive elective surgical procedures performed annually in the United States [1]. At present, predictive models suggest that the volume of procedures will continue to grow, with the projected growth of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) reaching 330% and 382%, respectively, by 2060 [2]. The Centers for Medicare & Medicaid Services (CMS) recently reported over seven billion dollars of annual reimbursement for 400,000 TJA hospitalizations, a value likely to multiply based on future TJA volume predictions if alternative payment models (APMs) are not implemented [3]. TJA represents the single largest expenditure for CMS procedures [4]. CMS has already moved TKA off of the Inpatient-Only List (IPO), and THA will not be far behind. In July 2019, CMS released its calendar year (CY) 2020 Medicare Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems Proposed Rule. The included proposed changes were to remove THA from the IPO, to add TKA to the ASC Covered Surgical Procedures List (CPL), and to set the TKA payment rate at $8639.97 [5]. Outpatient TJA bundles will be part of the next round of APMs released by CMS. In an effort to control the current and predicted unsustainable costs for healthcare, APMs that focus on performance, rather than a fee-for-service (FFS) model, have been initiated with success. In 2011, CMS implemented the Bundled Payments A. E. Roy (*) Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, USA e-mail: [email protected] O. R. O’Neill Department of Orthopedics, Sports Medicine, Twin Cities Orthopedics PA, Edina, MN, USA R. Iorio Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA © Springer Nature Switzerland AG 2020 G. R. Scuderi et al. (eds.), Rapid Recovery in Total Joint Arthroplasty, https://doi.org/10.1007/978-3-030-41223-4_3

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for Care Initiative (BPCI), resulting in financial and performance improvements in the public sector [6]. Additionally, insurers have also experienced similar improvements in the private sector with the implementation of bundled payment programs. Bundled payment programs are the present for some but undoubtedly the future for nearly all TJA providers. These programs are essential in the overall goal of reducing healthcare costs while improving healthcare quality. Moreover, outpatient total joint arthroplasty (OTJA), or TJA delivered in a noninpatient setting, is an essential element to successful commercial bundled payment programs when set up properly. These programs can be defined in many ways, but simply they comprise 24 h or less of hospitalization and utilize the advancements in total joint replacement programs, which have facilitated early discharge, rapid rehabilitation, and enhanced recovery. Nontraditional TJA programs can deliver TJA with sameor next-day discharge, thus avoiding the high cost of inpatient medical centers as the primary site of care. Care delivery vehicles can be ambulatory surgery centers (ASC), care suites, concierge destinations for overnight stays after ASC surgery, or designated portions of inpatient facilities that cater to the enhanced recovery TJA population. Commercial insurers have gravitated to bundled payment programs for the OTJA experience. Establishing OTJA within a bundled payment program is a multifaceted process that involves creating a vision and strategy, defining the appropriate patient population, and approaching the individual OTJA as an episode of care [6]. In this chapter, we will discuss insurance contracting by outlining the important considerations and steps necessary for creating a bundled payment program capable of reducing overall episode costs, improving quality of care for patients, and allowing the surgeons and sites of care to profit from these procedures.

Vision and Strategy Establishing a vision and subsequently a strategy for successful OTJA begins with understanding the multitude of stakeholders involved in a bundled payment program. Most importantly there are the patients, but also there are the care providers, payors, institutions, insurers, and manufacturers [6]. It is the role of these nonpatient stakeholders to work together in an effort to provide optimized, lower cost, quality healthcare. As the care provider creating a bundled payment program, it is important to discover and research the payors in your geographic area early in the process, which may include Medicare Advantage, commercial carriers, and/or self-insured employers [6]. The necessary data to create a bundled payment program includes the episode cost of care in your individual market and the true cost to deliver care. Episode cost of care data can be obtained from patients (Explanation of Benefits (EOB) form), employers, and the insurers themselves. With this payor market data in hand, cost can be compiled to actually deliver the care. It is critical that true costs be calculated for the episode. Implants, anesthesia, pharmacy, hospital staff, supplies, physical therapy, durable medical equipment,

3  Insurance Contracting for Outpatient Arthroplasty Programs

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and every component of the postdischarge costs of the patient’s episode of care need to be considered. These costs are not the same for every hospital and may vary by geography. Without true cost accounting, the episode pricing becomes an estimate with considerable risk on the side of the providers. One can be sure that the insurer knows their current costs and will only agree to an episode price less than current incurred episode costs. Negotiation then will result around the quality of care provided, amount of upside risk tolerated by the providers, and how much of a discount will be provided to the insurer. Adding value to the overall OTJA episode of care, and subsequently to each stakeholder, is only possible when a team approach to improving quality of care, while simultaneously decreasing cost, is adopted. We will dive further into the importance of the team approach, and how to align partners toward the common goal, later in the chapter. In addition, the creation of dedicated orthopedic care facilities is a central strategy in establishing a successful OTJA practice within a bundled payment program. The concept of orthopedic care suites is attractive for the delivery of OTJA.  These suites can be part of a freestanding facility or associated with a larger inpatient facility [6, 7]. Although same-day OTJA is steadily increasing in popularity, many patients still benefit from short-term supervised medical care. As a result, creating an intermediary, outpatient home for these patients is financially responsible. Orthopedic care suites increase efficiency by providing all essential healthcare services in one location, including onsite physical therapy, primary care physician management, dietary services, medications, 24-h nursing care, and laboratory testing. Additionally, these suites are geographically located within close proximity to the ambulatory surgery center (ASC), which entails additional cost-saving benefits. Orthopedic care suites are designed to provide a comfortable yet safe postoperative recovery environment that competes with the traditional hospital stay, without the challenges of a fully outpatient experience. Patients stay in the care suites based upon their clinical circumstances, typically overnight. Unlike 23-h stay rules in an ASC, where the patient has to be discharged before cases start the next morning (typically at 0600), the care suites do not have this requirement, and patients can be discharged the next day after they have received other ancillary services such as physical therapy. When utilized appropriately within an established system, orthopedic care suites have been shown to reduce overall cost by 30% while increasing patient satisfaction and outcomes [6, 7].

Defining the Bundle Within a bundled payment program, OTJA is approached as an episode of care. The episode of care in OTJA is a complex process that involves thoughtful patient selection and patient optimization, as well as a concrete definition of the episode of care, including when it will begin and end [7]. Defining which stakeholder is the episode initiator and which stakeholder will take on the risk of the episode is a key decision in this process.

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In a bundled payment program, nonpatient stakeholders are at risk of financial loss as a bundled payment typically covers all care provided to an individual patient during an episode of care, including readmissions during that episode. Depending on the individual program, compensation for each episode of care is established at a set rate and does not vary based on patient risk factors [8]. As a result, selecting the appropriate patient population for OTJA is vitally important to ensuring success for all nonpatient players involved. The at-risk stakeholder can be the hospital or site of care, the surgeon, or a combination of both. Episodes can also be defined as hospital cost only or designed to eliminate more high-risk patients. Obviously, the less risk taken, the less compensation given.

Patient Selection Risk stratification procedures allow high-risk patients to be identified while also allowing for the natural transition to discussions regarding medical optimization. Once medically optimized, patients can be reevaluated for surgery with risk reassessed, and subsequently directed toward either an outpatient or hospital-based pathway, or no surgery at all if risks continue to outweigh potential benefits. OTJA lends itself to less high-risk patients. Inherently, hospitals are sensitive to having low-risk patients diverted from their inpatient facilities to OTJA sites, thus increasing their exposure to high-risk patients. This presents an excellent opportunity for partnering with inpatient hospital facilities to develop alternative OTJA sites in conjunction with surgeons as part of a shared-risk, comanagement arrangement. Failure to risk stratify appropriately can lead to value loss centered around the primary inpatient stay, specifically in the instance of “bundle busters,” who are essentially high-risk patients who when mismanaged can incur unsustainable hospital costs [9]. Additionally, subsequent readmissions within the established episode of care can lead to value loss. Within 90 days of TJA, readmission rates have been shown to range from 6% to 15%, resulting in up to 19% of bundled payment loss in a CMS population [10]. Furthermore, studies have shown an association between specific patient risk factors and readmission and, moreover, that these risk factors are highly prevalent in the patient population seeking TJA [6]. At New York University Langone Medical Center (NYULMC), the Perioperative Orthopaedic Surgical Home (POSH) was established to identify patients at high-risk for readmission. Led by surgeons, the POSH essentially targets and evaluates eight modifiable risk factors that are scored by the “readmission risk assessment tool (RRAT) (Table  3.1) [7, 11]. The eight modifiable risk factors assessed are as follows: (1) Staphylococcus aureus colonization; (2) tobacco use; (3) obesity; (4) cardiovascular disease; (5) venous thromboembolic disease; (6) neurocognitive, psychological, and behavioral problems; (7) physical deconditioning; and (8) diabetes. An RRAT score of ≥3 is associated with a twofold risk of readmission and automatically prompts a discussion regarding medical optimization and subsequent referral to medical specialists and programs,

3  Insurance Contracting for Outpatient Arthroplasty Programs Table 3.1  Readmission risk assessment tool (RRAT) [12]

Risk factor 1.  Staphylococcus aureus colonization 2.  Tobacco use 3. Obesity  BMI >40   BMI 35–39.9   BMI 30–34.9 4.  Vascular disease (i.e., cardiac, cerebral) 5.  Deep vein thrombosis (DVT)   History of pulmonary embolism (PE) or DVT  DVT risk factors 6. Behavioral, cognitive, and/or psychological ailments  Alcohol or narcotic abuse/dependency   Neurocognitive ailments (i.e., brain injury, dementia, psychiatric condition)   PHQ-9 (patient health questionnaire) score ≥ 7 7.  Physical function   Unable to ambulate, or requiring assistance   Function, ambulation limited by medical condition(s) 8.  Diabetes mellitus   Blood glucose (fasting) > 180 mg/dl   Hemoglobin A1c > 8   Adequate control

35 Points 3 1 3 2 1 1 2 1

2 1 1

2 1

3 2 1

Adapted from Boraiah et al. [12]

as indicated. Utilization of POSH has resulted in a significant reduction in readmission rates when comparing patients who underwent medical optimization versus those that did not; 1.5% versus 4.1% and 4.6% versus 5.7% at 30 and 90  days, respectively [7]. Ideally, patients selected for OTJA within a bundled payment program will be the lowest risk patients who have been fully optimized medically. Such a situation will lead to the fewest complications during the primary admission, as well as the fewest number of readmissions, resulting in added value through cost reduction while simultaneously improving quality of care. Nonetheless, it is important to have a risk-stratification process established in order to appropriately identify those patients in need of more intensive preoperative care, and perhaps elimination from OTJA consideration. In addition to risk stratification, OTJA providers must establish strict exclusion criteria, especially during the early learning curve stages. Twin Cities Orthopedics, which has established a successful OTJA practice within a bundled payment program, utilizes the following strict exclusion criteria to obtain OTJA success: (1) BMI > 39; (2) diabetes mellitus with HbA1c > 7.5; (3) hemoglobin