A bundled payment ambulatory total joint program can improve quality of care and produce positive financial benefits to all involved, but only if risk is assessed and mitigated. The key is a smart inclusion criteria and risk assessment process.

“One of the prime motivators of anything in the world is dollars, and this is a significant cost savings to patients and insurers,” says Frank Rowan, MD, a partner with Delta Joint Management. “We’re financially viable, but we have to be very careful about managing risk. If someone gets an infected total joint, that’s a very expensive proposition, and we’re at risk for that. When you’re at full risk for this, you are extra careful.”

A major step toward managing risk is to establish thorough inclusion/exclusion criteria and conduct a risk assessment of each potential patient. Not every patient is a good candidate for ambulatory total joint surgery. A bundled total joint program is financially responsible for patient outcomes, so it would be very costly (and risky) to select patients with health complications.

“The key to determining whether a patient is a good candidate is the risk stratification tool that Dr. Rowan helped to design,” says Donna Garvey, CMPE, executive director of Delta Joint Management. “[Patients] have to answer a series of questions so we can establish whether they are a lower- or higher-risk patient based on their answers to these questions. We will not put them in a situation where they would be at risk, so his questions ensure we have good outcomes.”

The risk tool identifies potential red flags.

“Certain problems are absolutely no-nos,” Rowan says. “If someone is taking more than 10 mg of oxycodone a day, then there’s a high probability you won’t be able to discharge that person within 24 hours.”

Likewise, patients with A1c blood glucose of 7.5 or greater carry an elevated risk. The same is true for morbidly obese patients, whose body mass index (BMI) is more than 40 kg/m2. These individuals exhibit an infection rate that is twice as high as other patients, Rowan notes. Smoking, excessive drinking, and psychiatric problems also would not meet the inclusion criteria because these behaviors make it difficult to discharge a patient in fewer than 24 hours, he adds.

“You have to stop smoking first, and use alcohol no more than a couple of ounces a day,” Rowan says. “For patients, good behavior is part of it; the patient has to cooperate.”

When patients question the smoking prohibition, Rowan notes how much they’d save in copays by undergoing surgery in the outpatient setting. “How often in your lifetime as a smoker has someone offered to give you a couple thousand dollars to quit smoking?” The patient’s ability to be safe at home also is important. “One of our inclusion criteria is that you must have a family member who is at your side for the 48 hours minimum,” Rowan says. Patients who do not have a family member or friend who can be with them for two days could hire a nurse to fill that role. Although patients must pay for this service out of pocket, it would be less costly than if patients were to undergo surgery in a hospital, Rowan says. “Hiring some help could save a patient $2,000 in copays.”