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Bundled pay sparks debate for orthopedic surgeons

March 9, 2017

The national shift toward value-based payment systems, including bundled payments for all services associated with a major surgery, has orthopedic surgeons focused on cost-effectiveness and potentially expensive surgical complications here at the American Academy of Orthopaedic Surgeons (AAOS) 2017 Annual Meeting.

In one instance, CMS pays a flat fee, or “bundled payment,” for all care and services provided to patients undergoing total hip or knee replacement from admission to 90 days after discharge, as reported by Medscape Orthopedics.

“With the introduction of bundling, the orthopedic community has invested immense effort to identify the ‘bundle busters’ — that is, a list of all the complications that can occur early after total joint replacement and compromise the outcome,” said Javad Parvizi, MD, from the Rothman Institute at Thomas Jefferson University Hospital in Philadelphia, who is chair of the 2017 AAOS instructional courses committee.

Researchers are trying to identify which cases will likely involve such complications, he told Medscape Medical News.

The bundle approach is intended to encourage efficiency by removing the incentive to provide unnecessary services, but it can become problematic for providers if patients experience complications that require a lot of care in those 90 days.

A report on how periprosthetic joint infection can make a bundled payment system “difficult to sustain” for total joint arthroplasty will be presented by Elie Ghanem, MD, and orthopedic surgeon from Danville, Pennsylvania.

Rejecting Patients

Others have raised the concern that practitioners will begin denying care to patients likely to experience complications. Ways that bundled payments can be configured to prevent such a situation will be suggested by Daniel Berry, MD, from Rochester, Minnesota, whose team has done an analysis of risk factors from 38,889 total knee replacements.

A wider perspective — an analysis of the cost of treating arthritis symptoms in the year prior to a total knee replacement, and whether those treatments fit the recommendations of the AAOS — will provided by Nicholas Bedard, MD, from Iowa City in Iowa.

The question of whether sending patients home to recover after this sort of surgery actually saves money will be addressed by Andrew Fleischman, MD, from the Rothman Institute.

As payers search for ways to measure value, the use of patient-satisfaction surveys is increasing, but no metric is simple. A look at differences in the way men and women complete such surveys will be presented by Chukwuweike Gwam, MD, from the Rubin Institute for Advanced Orthopedics at the Sinai Hospital of Baltimore.

A wide spectrum of reports, including studies on controversial surgical techniques and the use of platelet-rich plasma injections, will also be on offer.

Head-to-Head Comparisons

Head-to-head comparisons of anterior and posterior total hip arthroplasty will be presented, respectively, by Tze Cheng, MBBS, from Monash University in Box Hill, Victoria, Australia, and Kenton Kaufman, PhD, from the Mayo Clinic in Rochester, Minnesota.

“I’m excited to hear about those,” said Alexander Gordon, MD, an orthopedic surgeon from the Chicago area, who will moderate the session.

He said he is also interested in studies being presented that will show that older techniques for hip replacement might be more successful than newer ones.

“Some of the registry data are showing that cemented fixation, something that was done several years ago and has waned in popularity in the United States, has better outcomes for certain populations,” Dr Gordon told Medscape Medical News.

And data on several new implants for hip replacements might be disappointing, he warned.

“The first decade of the twenty-first century brought us a lot of new implants, but a lot of them have not performed as well as we had hoped,” he explained. “We all have a lot of concern about new devices at this point.”

Studies looking at platelet-rich protein injections, in contrast, are generating excitement. These include comparisons with surgery for refractory tennis elbow, with cortisone injections for carpometacarpal joint osteoarthritis, with viscosupplementation for knee degeneration, and with placebo for acute muscle tear.

Prevention will also get some attention at the meeting. The slight increase in the reporting of concussions, particularly in young female soccer players, despite new rules meant to reduce these injuries, will be addressed by Wellington Hsu, MD, from the Center for Comprehensive Orthopaedic and Spine Care at the Northwestern University Feinberg School of Medicine in Chicago.

Dr Parvizi and Dr Gordon have disclosed no relevant financial relationships.

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