Bundled Payments Lead to Cost Savings and Improved Care in TJA


Medicare quality improvement program leads to cost savings and improved care in knee surgery, say researchers who presented findings this week at AAOS 2016.

Early results from a federal quality improvement program that was adopted for joint replacement surgery at a New York City hospital, reveal a cost savings and improvements after three years, say researchers who presented their findings on March 2 at the American Academy of Orthopaedic Surgeons annual meeting in Orlando.

​Richard Iorio, M.D., an orthopedic surgeon at New York University's Langone Medical Center, and colleagues, presented research on the 2013 implementation of the Bundled Payments for Care Improvement Initiative (BPCI) program. The BPCI program attempts to reward payers for quality, rather than quantity, of care. New York University's Langone Medical Center instituted a model 2 version of the initiative, which involves bundling payment for an entire inpatient acute care stay plus care up to 90 days after discharge.

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The researchers compared the metrics of length of hospital stay, readmissions, discharge disposition and cost per episode in the first year of the program to the same metrics in the third year. In addition to the payment bundling change, the medical center also instituted other changes in the second year of the program, including better coordination with home care services, infection prevention and a focus on discharging patients to home instead of to inpatient rehabilitation facilities.

The results of the comparison revealed improvements in these metrics as well as cost savings. The hospital performed 721 Medicare primary total joint arthroplasties in 2013, the first year of the intervention, and 785 in 2015, year three of the intervention. Over that time period, the average length of stay dropped from 3.58 days to 2.96 days, Dr. Iorio told Rheumatology Network, and discharges to inpatient facilities dropped from 22 percent to 28 percent. Readmissions dropped as well, from 7 percent to 5 percent at 30 days, from 11 percent to 6.1 percent at 60 days and from 13 percent to 7.7 percent at 90 days.

Key to making these changes was preoperative optimization of patients, Dr. Iorio said. The team introduced a Perioperative Orthopaedic Surgical Home (POSH) model, which included a risk assessment tool to predict the likelihood of a postoperative readmission. Patients at high risk had their surgeries delayed and were enrolled in programs to decrease their risk - interventions that ran the gamut from smoking cessation to weight loss programs to treatment with antibiotics to reduce Staphylococcus aureus colonization.

“Changes in care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the Bundled Payment for Care Initiative, thus bringing increased value to our TJA patients,” the researchers concluded.



Boraiah S, Joo L, Inneh IA, et al. Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty: A Readmission Risk Assessment Tool. The Journal of Bone & Joint Surgery 2015;97(23):1921–1928.  http://dx.doi.org/10.2106/JBJS.N.01196

Iorio R. Strategies and Tactics for Successful Implementation of Bundled Payments: Bundled Payment for Care Improvement at a Large, Urban, Academic Medical Center. The Journal of Arthroplasty 2015;30(3):349–350. http://dx.doi.org/10.1016/j.arth.2014.12.031



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