Medicare is expected to issue the final rule for the Comprehensive Care for Joint Replacement (CJR) initiative soon. As proposed, hospitals in chosen MSAs must be ready to take on this new challenge by January 1, 2016. The Connecticut Joint Replacement Institute (CJRI) at Saint Francis Hospital has performed more than 20,000 procedures since opening in 2007. CJRI has been on the forefront of bundled payments for joint replacements since implementing their first bundle agreement in 2010. CJRI will share the essential elements to developing a bundle program and the challenges of evolving towards a value-driven, risk bearing model in today’s healthcare environment. Attendee Takeaways: – Learn the essential ingredients to develop a successful bundle payment program – Understand the fundamentals of value-based healthcare – Learn how to create sustainable bundled payments and maintain a competitive edge in the marketplace About The Speaker: Maureen Geary is the Program Director at the Connecticut Joint Replacement Institute in Hartford, Connecticut. Maureen been involved with bundle payments since 2009. CJRI signed their first commercial contract in 2010. She leads strategic initiatives and new product development for the company. Maureen also provides consultative services for orthopedic organizations seeking to develop a bundled product or expand their service line.

1. Fundamentals of Bundles for Joint Replacement
Creating the Competitive Edge
Maureen Geary
Program Manager
November 19, 2015

2. • Opened in July, 2007 and has performed over
21,000 cases to date.
• CJRI is the most profitable service line at Saint
Francis Hospital.
• Saint Francis Hospital has a consulting agreement
with Connecticut Joint Replacement Surgeons to
manage CJRI.
• Surgeons and Anesthesiologists are in
private practice
Connecticut Joint Replacement Institute
(CJRI)

3. • The consulting agreement is a straight fee not a
gain sharing model.
• Dedicated Space and Resources:
• 3 Floors
• 100 FTE (management, clinical, para
professionals)
• Ancillary Services (Rehabilitation, Pharmacy,
Housekeeping, Integrated Medicine)
Connecticut Joint Replacement Institute
(CJRI)

4. The Step Ahead Program was established in
2010.
Three Participants:
1. Saint Francis Hospital & Medical Center
2. Connecticut Joint Replacement Surgeons
3. Woodland Anesthesia Associates
Bundle Program

5. Bundled Program Goals
Create a platform for care redesign to:
• Coordinate patient care
• Reduce variability
• Improve operational efficiencies

6. What is a “Bundled Payment”
“Single package price for a comprehensive
and specific set of healthcare services
delivered to a patient by multiple providers
over a defined period of time (Episode)”

7. Essential Elements to Develop and Implement
Your Bundle Program

8. Build a Multi Dimensional Team
• Administration and Physician Leadership
• Multidisciplinary Team
Legal
Finance
Clinical
Revenue Cycle
Operations

9. Define the Bundle
• Identify parties involved
• Define duties of each party
• Decide what is in/out
• Determine the timeframe
• Establish a warranty (if appropriate)

10. Duties of Each Party: Hospital
Provide the necessary infrastructure including:
• Facilities/ staff
• Support services
• Finance/Operations

11. Duties of Each Party: Surgeon
• Determine appropriateness for surgery
• Perform surgery
• Provide routine post-op in-patient care
• Adhere to guidelines and protocols

12. Duties of Each Party: Anesthesia
• Review eligibility and risk stratification
• Provide anesthesia services
• Adhere to best practice and protocols

13. Patient Criteria
• Patient under the age of 70 (non Medicare).
• Patients with either none or minimal systemic
disease.
• 11 factors (BMI, major depression, chronic
narcotic or alcohol dependency…)
• The criteria serves as guidelines and may be
modified to the patient’s overall assessment.

14. Determine Cost
• Hospital
• Surgeon
• Anesthesia
• Re-admissions and Complications

15. Define Quality Measures
• Re-admissions
• Complications
• HCAHPS scores
• Length of Stay

16. Engage your Physicians
Each Orthopedic Surgeon and Anesthesiologist
that performs bundle payment surgery will
participate in an in-service that outlines in
detail their specific responsibilities, the
protocols/best practices, and their own
personal financial risks for non-compliance.

17. Episode
Starts
Episode
Ends
Develop Care Maps

19. 1. Commercial Payers
2. Center for Medicare Services
3. Large Self-Funded Employers
4. Third Party Administrators
5. Large Primary Care Groups
6. Un-(or under) insured patients
Identify Potential Buyers

20. • Bundle payment was an A + B + C model
• ½ of the patients were excluded from the
bundle program due to anesthesia review
1st Commercial Contract

21. Challenges
• Reverted to manual systems and rework.
• Required additional resources across the
board.
• Lack of integrated systems to process claims
and payments.
• Hospital assumes the financial losses related
to co- pays and retro eligibilities.

22. • Commercial payors are seeking to shift
administrative tasks and risks to your bundle
program while reducing overall payment.
• Promise steerage of patients to your
organization.
Competing Priorities

23. Refining your Program

24. Physical Therapy Shift
• Patients admitted to the inpatient floor after
2 pm – only 20% ambulated.
• Develop a mobility technician program.
• Recalibrate certified nursing assistant and
mobility tech role into one role

25. Patient Ambulation - Mobility Program
July – August
Post Op
Day
Staff Type Ambulating the Patient Percentage Average Times
Patient
Ambulated
0
Mobility Techs, Nursing Assistants and Registered Nurses 93%
2.1
Physical Therapy 7%
1
Mobility Techs, Nursing Assistants and Registered Nurses 61%
4.6
Physical Therapy, Physical Therapy Assistant 39%
2
Mobility Techs, Nursing Assistants and Registered Nurses 60%
4.2
Physical Therapy, Physical Therapy Assistant 40%

26. Case Management
• Clinical oversight of patients should be only
for those going to an extended care facility
(less than 20% of patients)
• Shift work required to a highly skilled
administrative assistant

27. • Post acute spend was approximately $4,200
• Collaborating with post acute providers
Reference Based Model
• Desired Outcomes
• Metrics and Measurement
Changing the Paradigm
Post Acute Care

28. Third Party Administrators
New Book of Business
• Third party administrators are representing
the employers
• Seeking regional centers of excellence

29. Three Models
• Episode with the hospital stay
• Episode with readmissions
• Episode with post acute services

30. Things to Consider
• Who is in control?
• New way of doing business (telemedicine)
• Assume readmissions for patients that are
readmitted outside your network
• Assume costs for patients that don’t behave

31. Evolution of Our Bundle Payment
2009 Formation of a multi-disciplinary team to explore
bundled payment programs
2010 Bundle Program was established
2012 Signed a bundled contract with Payor
2013 Partnership with Harvard Business School. Project
lead with 30 organizations on Time Driven Activity
Based Costing (TDABC).
2015 5 national contracts as regional center of excellence

32. Creating a Competitive Edge
• Physician Leadership and Administration are
essential
• Know your value
• Evolving and Refining your business model

33. Questions

34. Thank You

35. 35
Streamlining Orthopedic Episodes of Care
www.wellbe.me

36. 36
Seeking Speakers
OrthoServiceLine offers a $500 speaking honorarium
for a 45-minute webinar and 15 minute Q&A from
your desktop and phone.
We are currently seeking speakers for our 2016
webinar series.
Interested? Send an email to ortho@wellbe.me.
Also seeking speakers for our next LIVE MSK
Leadership Summit – Tentatively March 30 in NYC!