"This has expanded to other clinical areas, and we've continued to develop care paths," said Monica Deadwiler, senior director of financial product innovation at the Cleveland Clinic, whose hospitals are participating in the BPCI program for joint replacements.
She believes, however, that bundled payment is best suited for procedural care, where there is a defined beginning and end to the episode, than for chronic disease management.
Selecting the right physician leaders is critical to success in engaging doctors in redesigning care pathways for bundled payment, Deadwiler said. At the Cleveland Clinic, the first priority was been to identify and get the buy-in of a physician leader to head the rollout.
Cleveland Clinic started working in 2011 on its BPCI program for joint replacement at Euclid Hospital, where the care redesign effort was led by the physician who was the hospital's president. After the Euclid model went live in 2013, the Cleveland Clinic adjusted it, documented the model in a "playbook," then engaged physician leaders at its other hospitals to tailor the redesign for those sites.
At each hospital, the physician leader convened a kickoff meeting with the doctors and other clinical staff involved in joint replacements to discuss how to streamline the pre-surgical, inpatient and post-acute processes and determine what resources were needed to achieve that. That was followed by multiple meetings to design and test the new model and offer any support physicians needed in their offices.
Use of data is central in engaging physicians in bundled-payment programs, the groups say. Signature Medical's Tessier said the surgeons with whom his group consults around the country had never seen detailed post-acute utilization and spending data before. They typically knew little about what happened with their patients after surgery.
That's why the data on where their patients went after surgery and the rate of adverse outcomes generated by post-acute utilization was "eye-opening" to them, he said.
"It's a process of getting the doctors in a room and looking at the data together," Tessier said. "It's not telling the doctors what to do. It's being the moderator so they can make evidence-based changes to their practice." The physicians sometimes use the data to call out colleagues who are outliers, he added.
Another key to the success of bundled payment is helping surgeons prepare patients and their families for the surgery and recovery phases. That includes working with patients to improve their health before surgery to optimize outcomes, such as encouraging them to lose weight or quit smoking. Many orthopedic groups have invested in hiring nurse practitioners or surgical assistants to do this patient education work.
"It takes more time and I barely break even, but I'm extremely proud of our program because the quality of care is awesome, and we're decreasing overall costs to Medicare," said Dr. Matthew Weresh, whose group, DMOS Orthopaedic Surgeons in Des Moines, Iowa, participates in the BPCI program. "Patients are happier, and they're recovering quicker."
Some of his partners, however, aren't taking as much time with patients as others are, he said. So his group puts pressure on them because the group as a whole only receives a gain-sharing bonus if it meets its overall cost and performance targets.
CHI St. Alexius Health in Bismarck, N.D., saw bundled payment coming and started working intensively with its surgeons on a care-improvement process several years ago. So it was well-prepared when it found itself drafted into Medicare's mandatory CJR program last year.
St. Alexius' collaboration features a close "dyad" partnership between Raumi Kudrna, a nurse who directs the hospital's total joint program, and orthopedic surgeon Dr. Duncan Ackerman, who serves as the conduit to the other surgeons. They have assembled impromptu teams to design rapid solutions for increasing same-day discharges after surgery and improving pain management.
Now HHS has proposed to make bundled payment for joint replacements optional in the Bismarck area. CHI leaders are waiting to see how St. Alexius and other CHI hospitals fared financially on the CJR program in 2016 before deciding whether to stay in.
Kudrna doesn't know what the decision will be, but she's sure the collaboration to improve care and reduce costs will continue. "We put a lot of things in place that seem to work for our patients," she said. "I don't see any of that changing, whether we opt in or out."
Correction: Dr. Geoffrey Cole is executive director of operations at Piedmont Athens (Ga.) Regional Medical Center. This story originally used his former title.