Key components to success with a bundled total joint same-day surgery program include a thorough risk assessment, pathways and protocols to ensure standardization, strong buy-in and communication with all providers and partners, and an emphasis on patient education.

Delta Joint Management, LLC of Greensboro, NC, operates a bundled total joint ambulatory surgery program that is working very well, says Steve Lucey, MD, co-founder and president of Delta Joint Management.

“We’re taking good care of patients, educating and standardizing, and our infection rate is zero,” Lucey says. “Our hospitalization rate is zero. Our DVT rate is zero. Our re-operation rate is 1.6%, compared with a national average of 3.5 to 5%.”

Bundling all pre-surgery, surgical, and post-surgery services into one contract is expensive; however, surgeons eventually will realize profits, Lucey says. “We believe in the business model because it’s a great one for everyone.”

When physicians take on 90 days of financial risk, they have to focus on preventing all hospitalizations, post-surgery infections, and other complications. The first step on this tightrope walk is a patient risk assessment. The program facilitators have to choose their patients wisely and appropriately. For instance, Delta Joint Management contracts only with private payers, which means patients are younger than 65 years of age, when they would be eligible for Medicare. But the biggest help is a risk assessment tool that identifies patients with potential surgical and post-surgery complications.

Additional steps in making a bundled total joint program successful include contracting with payers, standardization, data collection and assessment, and case management. Lucey and others involved in the program explain how the program was developed and how it works:

Find the right physician partners. “The four of us who formed Delta performed 1,800 total joints at the hospital each year,” says Frank Rowan, MD, an orthopedic surgeon and a partner with Delta Joint Management. “We were honing our skills to get the surgery down to a standardized procedure. We were minimizing blood loss, following protocols.”

Rowan, Lucey, and their colleagues developed a keen sense of knowing which patients would be discharged quickly. These were the patients who might be candidates for surgery in an ASC with a 23 hour and 59 minute maximum stay.

As the total joint program grows, the four original partners have added more surgeons to their group, but these doctors must meet certain criteria. Surgeons must perform at least 70 hip and knee surgeries each year, they must rank well below the national average in surgery complication rates, and they must agree to follow the protocols and standardized practices/orders.

The group seeks high-volume surgeons because of research that shows low-volume surgeons tend to log higher complication rates, Rowan says. Standardized practices also are very important. “It’s highly standardized,” Rowan notes. “If you want to be one of our surgeons, you have to use the standardized orders we came up with.”

There is no room in the group for physicians who want to go their own way, Rowan adds. Also, physician partners must demonstrate excellent outcomes, Lucey says.

Contract with insurers. “The huge part was getting four doctors from different practices together,” Lucey says. “We were competitors.”

Once that happened, the second big milestone was landing a contract.

“We went directly to payers and said, ‘We’ll save you 20% off your spend if you give us the check and we control it from there,’” Lucey says. “We believe that all decisions are clinical and patient care is the focus. However, each decision has financial implications as well. Therefore, who better than the physician to control the bundle?”

The physicians were convinced they could manage risk properly, and North Carolina Blue Cross/Blue Shield agreed, signing a contract with them. “We signed the first physician-controlled, outpatient total joint, private-pay, 90-day bundle in the country,” Lucey says.

Recently, Delta Joint Management signed a second contract with Aetna, and the company is working on reaching agreements with additional payers.

“A huge part of what we do is a paradigm shift, where physicians are in charge of the bundle,” Lucey explains. “This is a business mentality that is very unique. I take risk as the patient walks through my door.”

Since the risk includes what happens after the patient leaves and for 90 days, surgeons are incentivized to focus on quality of care and preventing complications and infections. Despite the bundled payment’s cost savings for payers, Delta Joint Management pays providers the same as what they would make without a bundled payment, he adds. “We’re doing a double whammy of value, increasing the numerator and decreasing the denominator, improving outcomes and decreasing cost,” Lucey says. “The only loser is the inpatient hospital system.”

Create pathways. In a bundled payment environment, standardization and best practice protocols are crucial to successful outcomes. Creating inclusion criteria was part of this model, but it was important to the Delta partners to research the literature and develop pathways and protocols.

“The pathways start when patients show up, continue through their stay, and follow up with how many days they receive of home healthcare and physical therapy visits,” Lucey explains. “There’s also a pre-op order set that everyone uses.”

The key to success is standardization, Lucey adds.

“The four of us have set up best practices. We use the same pain protocol, the same number of pills, the same type of pills, and we continually perfect that,” Lucey notes. “We’ve decreased use of opioid-based medications.”

Standardization is a big plus from the ASC’s perspective, says Jennifer Graham, RNFA, CASC, CNOR, the CEO of Surgical Center of Greensboro, LLC.

“For our team, instead of having 15 different doctors and 15 different sets of orders, we have one standardized pathway for every patient,” Graham explains. “For my team, that enables them to become engrained in how this program is running, and it continues to improve patient care.”

Delta Joint Management also created protocols for each downstream provider, says Donna Garvey, CMPE, executive director of Delta Joint Management. “We brought in a physical therapist to help us determine what we were going to do from the standpoint of developing protocols for their care,” Garvey says. “What was the criteria they’d have to follow in order to get patients to the right goals?”

Surgeons worked with physical therapists to determine how many visits were needed and the best pathway for handling visits. “All downstream providers understand that if a patient is not reaching goals as needed, then it is their responsibility to reconnect with the surgeon,” Garvey says.

Physical therapists have agreed to the arrangement, which they helped develop. “Surgeons met with physical therapists and asked how many visits were needed for a proper recovery from total joint surgery, and they asked what would be the fair compensation for a visit,” Lucey recalls. “That’s how we determined how much they would get.”

The protocol includes an expected range of physical therapy visits for each patient. If a patient reaches goals in fewer visits, then the physical therapy organization can end the visits, but receive the same payment. If the patient needs more visits, then the physical therapist organization must provide them and not expect more payment.

“If the patient reaches goals in eight or 20 visits, the physical therapy company receives the same payment,” Garvey says, noting that additional therapy must be approved by the surgeon. “So far, the only time we’ve seen this is when the patient has needed a manipulation, which is a normal potential outcome for recovery [after a total knee procedure]. If [patients] need a manipulation, then they are authorized for six additional visits.”

Use case management. Case management starts with inclusion criteria, putting a patient in the system, and setting up a plan of care, Lucey says. Each surgeon works with a case manager for assistance.

“We hired case managers to run the show,” he says. “The case management layer includes the informatics software, and there is a financial layer.”

Each patient is assigned an electronic plan of care. It prompts the case manager to call the patient after surgery. Case managers are in constant communication with downstream providers, Garvey notes. Case managers were trained to handle bundled payment cases through their work with a bundled payment program for Medicare patients. “The Medicare program is what led us to see a lot of excessive spending going on when physicians were not necessarily involved in the management of patients during the 90 days of care after surgery,” Garvey says.

For instance, Delta saw how patients were spending excessive time in skilled nursing facilities (SNFs) when they did not need that level of care, Garvey explains. Instead, under the ambulatory bundled total joint program, patients are sent home within 24 hours of surgery and receive assistance from case managers. These managers are registered nurses with rehabilitation experience, and they follow patients closely after patients return home, Rowan notes.

“Patients love it,” he reports. “I’ve had three patients where we did inpatient hips on one side and outpatient hips on the other, and every one of them said they won’t go back to the hospital for their surgery.”

Educate ASC staff. “We have off-site education for our teammates and doctors and in-house total joint education for teammates,” Graham says. “We’ve been working diligently to get a core group of teammates trained to facilitate a total joint team, and we continue to cross-train other teammates in the program.”