Pre-Operative Patient Profile in Total Hip and Knee Arthroplasty - - PowerPoint PPT Presentation

Pre-Operative Patient Profile in Total Hip and Knee Arthroplasty Predictive of Increased Medicare Payments in Bundled Payment Model

Beau Kildow, MD, Gerald Aggrey MD, Brian Dial MD, Vasili Karas MD,William Jiranek MD, Michael Bolognesi MD Department of Orthopaedics Duke University Medical Center December 9, 2017

Disclosures

• No disclosures related to this study
• I personally have no disclosures
• Disclosures for Co-Authors:

– Depuy (Royalties) – Biomet-Zimmer (Royalties) – Total Joint Orthopaedics (Consultant)

Introduction

• 1 Million arthroplasties yearly, 15B industry
• Est 200% (hips) and 600% (knees) ⬆ by 2030
• TJA is the highest volume of inpatient surgery for Medicare beneficiaries.

– 90% of Adult Reconstruction practices are >50% Medicare – Only 10% restrict or cap Medicare – 39% of AAHKS members participating in a bundled payment model

1. Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the Economic Downturn on Total Joint Replacement Demand in the United States. J Bone Jt Surg Am 2014;96:624 2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780

The Rules are Evolving

• Consequence of

– Increased financial burden on CMS – Regional variability in average price – Unaligned financial incentives and

• utcomes
• Bundled Payment Model

– Hospitals and physicians assume greater financial responsibility – Increased scrutiny in outcomes and patient selection

Regional Historical Payment Amounts Used to Calculate Target Prices

• Table1. Episodes initiating between 1/1/2017 and 9/30/2017

REGION 469 470 (1) New England $39,709.98 $22,904.94 (2) Middle Atlantic $41,403.62 $23,881.84 (3) East North Central $38,612.99 $22,272.19 (4) West North Central $36,136.37 $20,843.66 (5) South Atlantic $38,649.51 $22,293.25 (6) East South Central $38,544.50 $22,232.68 (7) West South Central $40,429.77 $23,320.12 (8) Mountain $36,371.47 $20,979.27 (9) Pacific $36,218.38 $20,890.96

Average

$38,452.95 $22,179.88

https://innovation.cms.gov/initiatives/cjr

Patients of All Shapes and Sizes…

Increased interest in patient selection for arthroplasty procedures and also defining costs related to patient comorbidities and preoperative patient profile.

Administrative vs Institutional Data

• Limited Data on Cost as it related to patient comorbidities

– Population based “Big Data” studies – Accuracy of coding data to estimate medical profile has been called into question

Purpose

• Identify pre-operative comorbidities that result in an increased financial

burden within a single institution

• Predict the specific increase in expenditure as a result of these comorbidities

within a patient cohort composed of Medicare beneficiaries that would qualify for inclusion in CJR.

– Secondarily, to identify whether there is a correlation between the number of comorbidities patients carry and their total Medicare payments across the bundled episode of 90 days.

Materials

• Perioperative Patient Profiles-Chart Review

– Demographic data – Age, gender, BMI, laboratory values – Detailed Comorbidity Profile

• Reimbursement Data-Directly from CMS

– Grand total cost to CMS of patient across proposed bundled period excluding costs of identified diagnoses/readmissions from CJR guidelines – Break downs

• Inpatient, outpatient, professional fees, readmissions, SNF, home

health, DME

Medicare patients who underwent primary total hip or total knee arthroplasty in 2013- 2014 at Duke

Omit readmissions and payments for excluded services within the episode of care

Results

• Study Population-694 patients from 2013 to 2014

THA 40% TKA 60%

Current smoker 6% Former smoker 46% Never smoker 48%

Table 3. Demographic results of 694 patient cohort

Mean Standard Deviation Age 69.93 9.23 Length of Stay 3.26 1.4 Gender 60% Female 40% Male BMI 29.89 5.8 Charlson-Deyo Score 1.75 2.36 Preoperative Hematocrit 0.41 0.04 Preoperative Glucose 93.1 24.11

Results

• Study Population: Coincident with Medicare population in the

southeast region

Cost Breakdown per Episode

Mean Cost per Episode: $23,046.40

Results

Results

• Specific comorbidities have a statistically significant resultant increase in Medicare

payments (p<0.05)

• Range $2,182 to $9,845 increase from baseline

Results

• Medicare payments increased with increasing number of

comorbidities (p<0.001)

• Mean of $671.04 increased cost per comorbidity

20,000 22,000 24,000 26,000 28,000 30,000 32,000 1 2 3 4 5 6 7 8 9 10 TOTAL MEDICARE PAYMENTS NUMBER OF COMORBIDITIES

MEDICARE PAYMENT INCREASE WITH COMORBIDITY

Conclusions

• First study to examine payments inclusive of index admission, professional

fees, total 90 day costs and CJR identified exclusions

• Specific, identifiable comorbidities increase Medicare payments in a 694

institutional patient cohort for primary total hip and knee arthroplasty

• Increased number of comorbidities = Increased Medicare payments

20,000 22,000 24,000 26,000 28,000 30,000 32,000 2 4 6 8 10 TOTAL MEDICARE PAYMENTS NUMBER OF COMORBIDITIES

MEDICARE PAYMENT INCREASE WITH COMORBIDITY

Discussion

• Value based Care  Need for predictive models of cost based on patient profile
• Identify modifiable comorbidities and chronic disease  Modify them! Preop!
• Medical Haves and Have Nots and Cherry Picking  Role of further stratification

Moving forward. Climbing higher.

CJR – Risk Stratification Guidelines for Elective Primary Total Knee, Hip, Ankle Replacements- Duke Health System Consensus or Evidence Based- 2016

• 1. BMI 40 or greater
• 2. Active smoker- must begin cessation program
• 3. HgA1C > 7.5% (>8%?)
• 4. Albumin of 3 or less (?3.4 or less)
• 5. Anemia - Hgb less than 11
• 6. Thrombocytopenia- platelets less than 50k
• 7. ESRD on dialysis
• 8. Coronary stenting with or without AMI within the past 6 months (?12 months)
• 9. Stroke or TIA within previous 6 months
• 10. Any active infections; any open wounds on the lower extremity posted for

surgery

• 11. Other significant issues- e.g. uncontrolled hypo-hyper thyroidism/

hyperparathyroidism, ASA 4, COPD on oxygen, etc.

• 12. Chronic high dose narcotic use (addiction)

Patients that do not meet these criteria may occasionally receive surgery if reviewed and approved by a faculty panel at Preoperative Conference.

Current Practice at Duke

Comprehensive Care for Joint Replacement Model (CJR by CMS)

• Mandated Bundle Payment model- Medicare Part A & B- Section 1115A of the

Social Security Act- started April 1, 2016- Lower Extremity Joint Replacements, participant hospitals held financially accountable for quality and cost of 90 day episodes for MS-DRG’s 469 (with MCC) and 470 (without MCC)

• 67 Metropolitan Statistical Areas (791 hospitals) for 5 years; CMS sets pricing

targets for both DRG’s with or without hip fractures (primary total hips, total knees, and total ankles); standard fee for service payments with retrospective reconciliation (about 12-18 months later- maybe)

• Quality metrics- Hospital level risk- standardized complications (NQF#1550)-

50%, HCAHPS (NQF#0166)-40%, patient reported outcomes (PROMIS- Global Health+Pain, HOOS, KOOS, Ankle)-10%; point system by percentile rank; rated excellent, good, acceptable- affects reconciliation payment or discounts repayment

• Potential gains/losses calculated by CMS- +5%- Year 1; +/-5% Year 2; +/-

10% Year 3, +/- 20% Year 4 and 5 (Hospital at risk- stop loss of 50% any episode; and pay for cumulative savings- also stop gain in any given year)

• Waivers- 3 night hospital stay for SNF (year 2); payments for home visits or

telehealth; gain sharing with collaborators (including surgeons)

• Patients maintain freedom of choice; required CMS bundle disclosure forms

DRG 470…

DRG 469…

Comorbidities Evaluated

Table 1. Preoperative Comorbidities included in the development of a detailed patient profile

Preoperative Comorbidities

Congestive Heart Failure Arrhythmia Valvular Disease Circulatory Disease Peripheral Vascular Disease Hypertension Paralysis Neurologic Disease Chronic Pulmonary Disease Diabetes Mellitus Hypothyroidism Renal Failure Liver Disease Peptic Ulcer Disease HIV/AIDS Lymphoma Metastatic Cancer Non-Metastatic Tumor Rheumatoid Arthritis Coagulopathy Obesity Recent Weight Loss Electrolyte Disorder Anemia Alcoholism Drug use Psychoses Depression

Demographic Data

Gender Surgery Smoking Status Age BMI