GAINESVILLE, Fla. — Hip and knee replacement surgeries represent the highest line item in the federal Centers for Medicare & Medicaid Services, or CMS, budget. Still, the federal government wants hospitals to make further improvements in cost and quality.
It’s a daunting challenge since the procedures are already considered cost-effective.
A redesign of the joint-replacement program by the University of Florida College of Medicine’s department of orthopaedics and rehabilitation, however, managed to lower costs while shortening hospital stays and reducing both readmissions and complications, according to a new UF Health study published in the journal Arthroplasty Today. Additionally, pain management and mobility after surgery were dramatically improved, allowing patients to recover at home instead of at rehabilitation facilities, the study said.
UF Health physicians said their experience may provide a blueprint for implementing a value-added program that does not “cherry-pick” patients to meet cost requirements imposed by the CMS.
“Our concept is that any change that decreases cost shouldn’t affect patient outcomes,” said one of the study’s co-authors, Hari K. Parvataneni, M.D., an associate professor who is division chief of the adult arthroplasty and joint reconstruction program in the UF College of Medicine’s department of orthopaedics and rehabilitation. “And that’s the crux of value-based care. It’s basically quality divided by cost. Every change has to be based on what is best for the patient.”
The study looked at data for CMS and privately insured patients for the 12 months ending Jan. 31, 2017, comparing numbers to patients before the 2015 UF Health redesign. It found hospital length of stay fell from 3.5 to 2.1 days; discharge to home, rather than to a rehabilitation facility, improved from 62 percent of patients to 86.6 percent; and per-patient cost to CMS declined by 19.5 percent, or 11 percent below the target set by the agency.
Meantime, hospital readmissions fell from 4.9 percent to 3.9 percent, and joint-replacement complications fell from 2.3 percent to 1.9 percent.
Part of the impetus of the redesign was a bundled-payment model for Medicare and Medicaid reimbursement implemented by CMS to control costs, reward favorable outcomes and improve value in care, rather than traditional fee-for-service.
The study’s lead author, Chancellor F. Gray, M.D., an assistant professor in the UF College of Medicine’s department of orthopaedics and rehabilitation, said the department had been looking for synergies to refine care when the CMS mandated the changes in April 2016.
Starting in late 2015, the department created the patient- and family-centered care program, which emphasizes improving a patient’s experience through their whole joint replacement episode. This includes getting a patient safely home after surgery and avoiding unnecessary stays in rehabilitation facilities.
Patients are at a higher risk of infection and other complications in a hospital and rehab facilities, and they recover faster and more safely at home, researchers said.
“The longer you stay in a hospital, the more likely you are to be readmitted to the hospital, the more likely you are to end up in a nursing home,” said Gray. “So, it’s been helpful for improving outcomes to equip patients to get home sooner, and it also enhances recovery because, when you get home sooner, you start getting back to your life.”
A big piece of the redesign was to transform the culture across the care continuum so that health care professionals come to expect early mobility and safe, early discharge to home, the study said.
The program redesign also emphasizes patient education and gives patients access to a seven-day-a-week afterhours orthopaedic practice to avoid unnecessary and expensive visits to the emergency room. Additionally, the program hired a “nurse navigator” to help coordinate patient care and address patient needs, in addition to increasing and optimizing the use of regional anesthesia such as nerve blocks.
“We’re trying to get away from the sort of narcotic heavy, general anesthesia that leaves patients feeling very fatigued and drowsy and confused, which helps with pain but doesn’t help with recovery,” said Gray.
Catheters that deliver nerve-blocking agents to the surgery site also reduce the need for pain medication through the hospital stay and beyond. These have a side benefit of making the patient more mobile and able to participate in rehabilitation, which in turn helps get them out of the hospital faster, Gray said.
Further patient gains are expected, he said, as the program gathers experience and is refined.
Additional authors of the study are Hernan A. Prieto, M.D., an assistant professor in the UF College of Medicine’s department of orthopaedics and rehabilitation, and Andrew T. Duncan, M.B.A., P.T., D.P.T., executive director of the department.