Cleveland Clinic Health System team members writing in NEJM Catalyst share the five essential factors for their success under Medicare's Bundled Payments for Care Improvement (BPCI) program and discuss the broader lessons for thriving under value-based payment models.
A breakdown of the four BPCI bundling models
BPCI is comprised of four "broadly defined" care models that establish bundled payments for multiple services received during an episode of care.
The Clinic selected Euclid Hospital as a pilot facility to test the system's approach to BPCI, and it selected major joint replacement of the lower extremity as its episode of care. Under BPCI Model 2, CMS starting in 2013 initially paid the hospital on a fee-for-service basis for the episodes of care, then either shared savings or recouped payments from the hospital depending on how its actual expenditures through 30 days post-discharge compared with a target price based on the facility's historic experience.
Goals and organization
To prepare for BPCI, the Clinic's department of orthopedic surgery developed "standard clinical care paths" for total joint replacement based on existing best practices in order to increase quality and reduce care variation. For instance, they emphasized promoting speedy recoveries, such as by, whenever possible, initiating physical therapy on the same day as surgery.
The Clinic then created "a standardized methodology of care redesign that could apply to other risk-sharing arrangements," with a three-pronged approach that it calls "Complete Care." It includes:
- Using evidence-based best-practice guidelines to ensure high-quality care;
- Establishing a designated care coordinator position to work with patients and their families through the entire episode of care; and
- Focusing on care transitions into the post-acute setting to reduce fragmentation and improve long-term patient outcomes.
Outcomes
The Clinic's BPCI pilot was both clinically and financially successful. Between October 2013 and September 2014, Euclid treated 271 beneficiaries through the program. Compared with the baseline period of first quarter (Q1) 2013, during the intervention period:
- Average length of stay declined from 3.4 days to between 2.67 and 3.01 days;
- The rate of catheter-associated urinary tract infections declined from 5.2 per 1,000 patients to zero;
- Discharge to home increased from 39 percent to between 68 percent and 75 percent; and
- Patient experience survey scores also increased during the intervention period.
- Euclid also held costs to 9.8 percent below the target set by BPCI, which resulted in $362,818 in savings for Cleveland Clinic and $159,571 in savings for CMS.
Lessons learned
The authors share five factors they say are "essential for success when redesigning care for bundled payments":
- Prioritize physician engagement. Identify a physician champion early, and then bring in additional physicians as care redesign progresses.
- Leverage care coordinators. "Establish a formal specialty care coordinator position," the authors write, who can serve as a single point of contact for clinicians, staff, patients, and their families.
- Educate stakeholders and use consistent messaging. Train and educate patients, staff, and clinicians so they share expectations about how care will be delivered during the entire episode of care.
- Partner with post-acute providers. Close coordination during care and after care transitions can improve outcomes and control costs.
- Create a central repository of BPCI knowledge. "Create an online module to provide hospital clinical or professional staff with information on BPCI, beneficiary protections, program waivers, and an anonymous line for reporting issues to Cleveland Clinic," the authors suggest.
Based on Euclid's success, the Clinic has now expanded its participation in BPCI to nine other hospitals, the authors write (Mouille et al., NEJM Catalyst, 6/2; CMS website, accessed 6/9).
One step toward CJR success: Know your joint replacement episode spending
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