Iorio Richard, Bosco Joseph, Slover James, Sayeed Yousuf, Zuckerman Joseph D
1Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY.
J Bone Joint Surg Am. 2017 Jan 4;99(1):e2. doi: 10.2106/JBJS.16.00066.
The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.
医疗保险和医疗补助服务中心（CMS）于2011年实施了“改善护理综合支付（BPCI）”计划。通过BPCI，参与支付协议的组织要对护理事件承担绩效和财务责任。要取得成功，BPCI要求在维持质量的同时降低护理成本。这就需要医生和医院的利益融合。骨科医生必须在成本控制、手术安全和质量保证方面发挥领导作用，以提供具有成本效益的护理。由于大多数骨科医生独立执业，并非受雇于医院，因此成功实施捆绑定价可能需要医生与医院的合作模式（如医生-医院组织）或医疗机构与医院之间的合同收益共享安排。在BPCI模式下，医院、外科医生或第三方共享奖励，但要共同承担捆绑支付的风险。对于患者而言，成本节约必须与质量指标的维持或改善相关联。然而，质量的定义可能各不相同，过程和结果的奖励也可能不同。在捆绑定价协议中应考虑潜在并发症的风险分层，以防止排除患有严重合并症和护理成本较高的患者（如接受假体治疗的髋部骨折患者）。捆绑定价的成功取决于规模经济；较小的机构必须谨慎行事，因为一名高成本患者可能会对其整个项目的财务状况产生重大影响。CMS建议每年至少有100至200例病例。我们还建议参与者利用技术来提高效率，并为实施捆绑支付提供尽可能好的环境。需要对基础设施进行大量投资，以开发改善护理协调、管理质量数据和分配支付的项目。较小的机构可能难以投入资源进行这些基础设施变革，不过一旦启动，变革可能会实施得更彻底。在此，我们讨论我们在三级医疗学术医学中心开展早期全关节置换BPCI的经验。
