This document provides guidance on implementing bundled payment programs for orthopedic procedures. It discusses assembling a multidisciplinary team, defining the bundled episode of care, managing financial risk, monitoring outcomes, and aligning providers through contracting. Key steps include selecting high-volume procedures, setting patient and provider criteria, determining the bundled price and what is included/excluded, identifying who will manage claims, and establishing quality metrics to measure success. Regular communication between all parties is emphasized to ensure smooth implementation and monitoring of the bundled payment program.

1. G A B R I E L L E W H I T E , R N . C A S C
EXECUTIVE DIRECTOR
AMBULATORY SERVICES &
NETWORK DEVELOPMENT
H O A G O R T H O P E D I C I N S T I T U T E
C O N T I N U U M C A R E A D V I S O R S
C C A D V I S O R S 1 @ G M A I L . C O M
Getting Started with Bundled
Payment for Orthopedics
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2. Background
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 Hoag Orthopedic Institute [HOI]
orthopedichospital.com / hoioutcomes.com
 Orthopedic Surgery Center of Orange County [OSC]
OSCOC.com
 First global in 2008/09 - OSC
 Global TPA – OSC
 Global cash -OSC
 Bundled pilot – HOI
 Commercial bundle – HOI
 > 250 global and bundled episodes

3. Our objectives
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 Create change in payment model
 Improve care
 Align providers
 Provide value
 Volume
 Demonstrate success

4. Definition
4
A bundled payment is an all inclusive price that covers the cost
of facility and professional services related to a specific
procedure over a specified period of time that may or may not
include a warranty

5. 5
$
Facility
ProfessionalWarranty

6. Bundled example
 Total knee arthroplasty
 DRG 470
 CPT – 27447
 ICD – 81.54
 Episode – admission > 90 days
 Includes all care related to index procedure
 Excludes – SNF, Home Health, care and procedures not related
to index procedure, bilateral procedures
Admission > discharge > post op care up to 90 days
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7. Global example
 Total knee arthoplasty
 DRG 470
 CPT – 27447
 ICD – 81.54
 Episode – admission > discharge
 Includes all care related to index procedure during hospital stay
 Excludes –care following discharge and procedures not related
to index procedure, bilateral procedures
Admission > discharge
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8. 8
bundle
team
episode
Manage
risk
Outcomespayers
Claims
monitor

9. Team
 Team selection
¡ Clinical
¡ Administration
¡ Support services
 Roles
 Communication
 Meetings
 Reporting
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10. Team
Hospital/facility
Coordinator / project lead – connect the dots
 Physicians
surgeon
anesthesia
Internist
 Nursing
 Administration
Contracting
Revenue cycle
Benefits
Registration
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11. Team
Professional
Coordinator – liason with hospital
 MD office lead
Revenue cycle
contracting
benefits
patient coordinator
 Anesthesia
 Internist
 Other
11

12. Team
Patient
Communicate
what
why
how
when
Educate
12

13. Episode
13
 Procedure
¡ Predictable
¡ High volume
¡ Known cost
¡ Known outcomes
 Included
 Excluded
 Time line
 Warranty

14. Manage risk
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Patient selection
 Safe surgery
 Health status
¡ BMI <38
¡ ASA 1-2, 1-3
¡ Medical history

15. Manage risk
Providers
 Volume
 Quality
 Outcomes
 Cost
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16. Warranty
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¡ Length
¡ Inclusions
¡ Exclusions
¡ Manage risk
¡ Provider data
¡ Self insured
¡ Re insurance
¡ Manage timeline

17. Outcomes
 Quality benchmarks
 Volume
 ALOS
 SSI
 DVT/PE rate
 Re admission
 Claims
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18. Manage cost
 Reduce waste
 Do what is necessary/best practice
 Consider outcomes & risks
 Know cost data per provider
 Standardize
 Work with vendors
 Share savings
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19. Payers
 Commercial
 Employers
 Private pay
19

20. Payers
 What do they want?
 Payer roadblocks
 Payer concerns
 How will they benefit?
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21. 21
Hospital Surgeon
Anesthesia Other
professional

22. 22
MD
HospitalPayer

23. Claims
 Align all providers
 Pricing
 Data
 Who will manage claims?
 Who will manage payments?
 Process
 Contract between providers
 Risk pool?
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24. Claims
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 Pre procedure
 Post procedure/episode
 One claim / multiple providers
 One check / multiple providers
 Coordination
 Payer concerns

25. Communication
Bundled
alert!
surgeon
facility
Other
professional
providers
25

26. Communication
 Patients
 Providers
 Episode start > end
 Outliers
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27. Care redesign
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 Align providers
 Claims management
 Share risk
 Standardize care
¡ Navigators
¡ Pre admission screening
¡ Infection prevention
¡ Transfusion rates
¡ Vendors

28. Provider contracting
 Facility
 Surgeon
 Surgeon assistant
 Anesthesiologist
 Other
¡ Hospitalist
¡ Radiologist
¡ Pathologist
¡ Cardiologist
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29. Benefits
 Improve quality and outcomes
 Reduce cost of care
 Change from FFS
 Payers/employers want
¡ Solutions & change
¡ Price predictability
¡ Reduced costs
¡ Risk sharing
 Alignment
 Share in savings & success
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30. Early Road blocks
 Communication
 Payers
 Providers
 Knowing costs
 Knowing data/outcomes
 Process change
 Risk sharing
 Price setting
 Claims management
 Warranty
 Risks
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31. Monitoring success
 Monthly reports
¡ Revenue cycle
¡ Performance improvement
¡ Peer review
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32. Getting started
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¡ True & trusted leaders
¡ Payers
¡ Procedure
¡ Length of episode
¡ Warranty
 Inclusion
 exclusion
¡ Providers involved
¡ Data
¡ Rates
¡ Claims management
¡ Outcomes

33. Getting started
 Cash global
 Commercial global or bundled arrangement
 Employer global or bundled arrangement
 Consider a pilot
 Start small
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34.  Align providers
 Build the team
 Select high volume, predicable procedures
 Patient selection criteria
 Define the episode of care –start to finish, what it
includes
 Determine the bundle price, what it includes and
excludes
 Provider selection criteria
 Define quality metrics to be met and monitored
 Determine who will manage claims and payments
 Identify interested payers
 Educate
 Monitor the program
 Communication
 Keep it simple
In a nutshell

35. -
THANK YOU!
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