Navigating the New Frontier: Quality Improvement Strategies to Prepare for Bundled Payment Scheme for Lower Extremity Joint Replacements

Abstract

Background: A number of alternative payment schemes aiming to restructure the health system and realign financial incentives have emerged as potential strategies for achieving higher value within healthcare. Interest has grown particularly around bundled payments for episodes of care. The Centers for Medicare and Medicaid Services (CMS) has initiated testing scale-up of the bundled payment models nationally through the Comprehensive Care for Joint Replacement (CJR) Program. Concerns and questions regarding how and whether bundled payment models will be effective in raising value in lower extremity joint replacement (LEJR) care exist. We sought to evaluate the valueraising potential of bundled payments and determine the most effective strategies for implementing bundled payment schemes for LEJR. Methods: A review of the literature was conducted to synthesize the empirical data available on effective strategies and known outcomes of applying bundled payments to LEJR. Relevant publications were identified using comprehensive search terms in Medline, reference mining, and ad hoc searches. To assess stakeholder readiness and plans for LEJR bundled payment reform, we sampled a small cohort of senior officials from hospitals in a large integrated health system in Boston, MA. A standardized semi-structured interview guide was used to assess stakeholder initial reaction to LEJR bundled payment models, planned strategies for lowering costs and improving quality, anticipated challenges to implementation, approach to care coordination with other stakeholders, strengths and challenges of CJR. Interviews were transcribed and analyzed for apriori and inductively-derived themes and subthemes. Results: Our systematic search identified 16 publications describing LEJR bundled payment demonstrations. Demonstrations of bundled payments for LEJR conditions generally reported achieving lower utilization and costs outcomes. However, quality metrics reported in captured demonstrations were limited and variable. Demonstrations that reported successful outcomes utilized some common care redesign strategies, including creation of standard clinical pathways, eliminating unnecessary use of rehabilitation services, and development of a care coordination infrastructure. Barriers to successful bundled payment implementation included failure to align stakeholders, low case volume, and high administrative burden. Eleven healthcare stakeholders took part in in-depth semi-structured interviews between December 2015-January 2017. Though stakeholders generally praised CJR as a step toward creating a more efficient health care system, they anticipated a number of challenges to implementation, including apprehension toward taking on risk, managing competing demands and particularly complex patients in tertiary care hospitals, and bridging fragmented vertical reporting structures between different stakeholder groups (i.e. physicians, care coordinators, postacute facilities).